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TREATISE
ON
DISLOCATIONS,
AND ON
FRACTURES
OF THE
JOINTS.
LONDON.
PRINTED BY F. WARR,
RED LION PASSAGE, HOLBORN.
o
TREATISE
ON
DISLOCATIONS,
AND ON
FRACTURES
OF THE
JOINTS.
BY SIR ASTLEY COOPER, BART., F.R.S.
SURGEON TO THE KING,
&;€., S;c., ^c.
FOURTH EDITION.
g LONDON '.C^
PUBLISHED FOH THE AUTHOR,
BY MESSRS. LONGMAN, HURST, REES, ORME, BROWN, AND GREEN, PATERNOSTER ROW ;
S. HIGHLEY, 174, FLEET STREET; T. & G. UNDERWOOD, 32, FLEET STREET;
AND COX & SON, ST. THOMAS'S STREET, SOUTHWARK.
MDCCCXXIV.
X
TO THE
STUDENTS OF SAINT THOMAS'S AND GUY'S
HOSPITALS.
My Dear Young Friends,
This Work having been composed for your use, my
principal object will be attained if you derive advantage
from it. I cannot, however, omit to embrace the oppor-
tunity of expressing my gratitude for the affectionate and
respectful manner in which you have always received me
as your instructor. Your parents and relatives, many of
whom were my pupils, are also entitled to my most grate-
ful acknowledgments ; they fostered me in early life ; and
by their friendship and recommendation have largely con-
tributed to procure to me a degree of success which, I
fear, is beyond my merits, and a course of uninterrupted
happiness which few have been permitted to enjoy.
Believe me, always.
Your affectionate Friend,
ASTLEY COOPER.
B
PREFACE
TO THE FOURTH EDITION.
It is incumbent on me to observe, that although I believe
the matter of this Work to be correct, and regard it as the
result of a considerable share of experience, yet, I am aware
that the reader may detect a too familiar mode of expression,
and may censure me for want of attention to its style. The
familiarity of the language arises from my desire to be per-
spicuous. I prefer a significant expression to a finely turned
sentence, just as I would a good plain suit to the finest
embroidered dress, and am ready to own, that I think much
more of the matter which I give, than of the manner in which
it is conveyed.
I am much indebted to my friends for their communications;
the life of man is too short to allow him, even with the greatest
industry, zeal, and opportunity, to witness all the varieties of
accident or disease ; and I should feel that I was not properly
discharging my duty, if I omitted to take advantage of all
the evidence which might be adduced by those on whom I
could depend.
b2
VIU PREFACE.
Whilst, then, I sincerely thank niy friends for their kindness,
I wish to state to them and to others, that they will always
oblige me, by giving me any information which it is in their
power to convey upon this or any other subject in surgery.
In looking over the following pages on dislocations, I feel
that my professional brethren will be disposed to think that
I have limited to too short a period the attempts at reduction.
It has been stated, that dislocations have been reduced at four
and even six months after the injury had been received, which
I am not disposed to deny; indeed, I have myself had an
opportunity of witnessing examples of the fact; but, excepting
in very emaciated, relaxed, and aged persons, I have observed
that the injury done in the extension, has been greater than
the advantage received from the reduction ; and, therefore, in
the case of a very strong muscular person, I am not disposed,
after three months, to recommend the attempt, finding that the
use of the limb is not, when reduced, greater than that which
it would have acquired by having remained in its dislocated
state. Let this be fairly represented to the patient; and then,
at his request only, the reduction should be attempted; but
" with all appliances and means to boot," the extension must
be very gradually made, and without violence, to avoid injury
to the muscles and nerves.
I have stated, that in fractures of the upper part of the
thigh-bone, the foot is generally everted; to which there is
PREFACE. IX
sometimes an exception; for I have seen a case of Mr. Lang-
staffs, surgeon in the City, in which the foot was inverted,
and the bones, although they rubbed against each other, had
not united.
Mr. Guthrie considers it probable, that the inversion of the
foot in fractures of the upper part of the thigh-bone, which
now and then happens, arises from a diagonal fracture through
the trochanter major. The gluteus medius and minimus, with
the tensor vaginae femoris, draw the thigh-bone forwards, and
roll it inwards. He shewed me a preparation which confirmed
this opinion.
I have received from Mr. Brindley, surgeon of Wink Hill,
an account of a dislocation of the os femoris, which the patient
is able to produce and reduce when he chooses ; the man is
fifty years of age. Mr. Morley, of Uttoxeter, has transmitted
to me a case of compound fracture of the head of the os
humeri ; the end of the bone was sawn off, the bone reduced,
and the patient did well ; the length of the limb differed but
little from that of the other. And Mr. White, of the West-
minster Hospital, has shewn me a case of dislocation of the
OS femoris from ulceration, in which the head of the femur was
sawn off, and the person recovered.
I have been accused of publishing doctrines, respecting frac-
tures of the neck of the thigh-bone, which differ from those of my
jnedical brethren, and this I am ready and proud to acknowledge;
PREFACE.
on the other hand, I have heard that I am abused for not
having acknowledged that others had previously given similar
opinions. To this animadversion I have only to reply, that I
began to deliver lectures in the year 1792, and that I never failed
in them to give publicity to the opinions which I have here
advanced. I have procured early copies of my lectures, taken
by some of my students, and I could obtain a great number of
others, which shew that my opinions of non-union were those
which this book contains. By a comparison of the dates of my
lectures, with that of the publication alluded to,* it will be
readily seen who had the priority in forming those opinions.
UNION OF THE FRACTURED CERVIX.
The earliest notes of my lectures, and I began to give lectures
in 1792, ran thus:
Fractures of the Thigh-Bone at its Cervix.
"These fractures seldom, if ever, become afterwards united,
for which two reasons may be given ; first, that the uniting
matter is thrown into, and lost in the joint ; and, secondly , that
the fractured portions of the bone are not in apposition, the
* Principles of Surgery, by John Bell, published in 1801.
PREFACE. XI
thigh-bone being drawn from its head (which still remains in
its socket) by the action of the glutei muscles."
Extract from Sir Astlev Cooper's Surgical Lectures, delivered
in the year 1793, tahen from the notes of Mr. Fiske.
" When a bone which forms part of a joint is fractured
transversely, union seldom takes place between the fractured
ends, as in the patella and olecranon; where the same effusion
of blood takes place, but is lost in the cavity of the joint, from
which it receives vessels and becomes of a ligamentous substance.
When the cervix of the os femoris is fractured, it becomes united
to the capsular ligament by bands ; the reason for this kind of
union taking place is exactly the same as in a trepanned skull;
for the action of the muscles inserted into the upper part of
the bone draws it upwards, and those into the lower part draw
it downwards, and the space becomes too great for the vessels
of the bone to shoot into the coagulated blood and form it
into bone. This, I think, will hold good, though it is different
from the opinion of many men."
Charles Fiske.
Saffron Walden;
Nov.Uth,'[^2L
Xll PREFACE.
From Mr. LvKVjr, of Fever sham.
Dear Sir,
I am sorry to say that my notes on your surgical lectures,
delivered in 1793, are very short: in the one on simple fractures
you said, " There are some fractures that happen in joints that
never unite, as in the neck of the thigh-hone ; the blood is extra-
vasated into the joint, and only ligamentous matter deposited, the
vessels shooting into the coagulum coming from the ligament.
Another reason is, the parts cannot be kept in apposition."
I remain, dear Sir,
Feversham, Your very obedient Servant,
Nov. 12th, 1824. Robert Lukyn.
From Dr. Pidcock, of Watford.
My dear Sir,
Ih a copy I made of the lecture on simple fractures there is
this brief remark on the subject of your inquiry : " In fractures
of the cervix femoris, the ends of the bone are never opposite to
each other ; the callus is thrown into the acetabulum, and union
never takes place."
Watford; I remain, very faithfully your's,
Nov. lith, 1824. John Pidcock.
Pupil in 1794-5.
PREFACE. Xlll
From Mr. Pullev, of Bedford,
Dear Sir,
I send you with much pleasure your observations on fractures
of the neck of the thigh-bone. You will find my language in-
correct in some parts, owing to the hurry of transcribing, arising
from the multiplicity of matters then to be attended to ; but I can
vouch for the accuracy of the statement, and had much rather
send you an exact copy of the lecture now in ray possession, not
knowing the reason of your present application.
" Fracture of the neck of the thigh-bone : — This fracture never
unites ; tell the patient this, and that he must be lame for life.
When the injury happens with persons not more than fifty-five
years of age, the recovery may be so far that the patient may be
able to walk with a stick ; but should it happen with very old
people, they will never after be able to walk out without crutches.
The fractured cervix does not unite, because the extravasated
matter, or coagulable lymph thrown out for union, is lodged in
the joint, so that it is not applied to the ends of the bone ; be-
sides, union cannot be effected, as the ends of the bone are so
far removed from each other. Attempts have frequently been
made to effect an union, but they have never succeeded."
I remain, dear Sir,
Bedford; Your most obedient Servant,
J^ov. I2th, 1824. John Pulley.
Pupil in 1796.
XIV PREFACE.
From Mr. IVeekes, of Hurtspur Point, Sussex?.
Dear Sir,
I am sorry I have been prevented answering your letter
before ; but upon referring to your lectures I find the following
observations, viz. :
" Of fracture of the cervix femoris : This is of frequent occur-
rence, but seldom or ever happening but in people of advanced
age. These fractures are often supposed to be cured, but in
reality they never are. People, after these fractures, should
always walk with a stick ; and if they are stout and fat, crutches
are admissible.
" The reason why fractures of the cervix femoris do not get
well so soon as fractures of the trochanter, is, that in the former
the callus becomes extravasated in the joint, and renders union
of the bone impracticable."
I remain, dear Sir,
Your very humble Servant,
Hurtspur Point, H. Weekes.
Sussex:.
Pupil in 1796.
From Mr. Overend, of Sheffield.
Dear Sir,
In referring to my notes of your lecture on fracture of the
cervix femoris, delivered in the year 1797, I find the following
PREFACE. XV
observations. After describing the appearances indicating the
fracture of this part of the thigh-bone my notes state :
" A crepitus in fracture of the cervix femoris can never be
observed, originating from the two extremities of the broken
bone never being in contact, and, consequently, a bony union
never takes place ; in the first instance, from the want of contact ;
and, secondly, from extravasation surrounding the affected part,
which progressively becomes vascular, and forms a ligamentous
union, if union at all."
Your obedient humble Servant,
Sheffield; Hall Overend.
Nov. Uth, 1824.
Dr. Jeffries, of Liverpool, took the following notes of
my Lectures in the year 1797.
" In the cervix femoris, an union never takes place ; the leg
is much the shortest, the foot and knee turned outwards, and
great motion at the hip-joint : occurs only in old people. The
fractured surfaces become smooth by callus, but no union ever
follows, because the two pieces of bone are never applied, and
the callus matter is lost within the cavity of the joint."
From Mr. Alexander, of JVewbury.
" The cervix of the os femoris is a part that never unites. It
c 2
Xvi PREFACE.
is an accident which generally occurs in old people after the
age of fifty-six; the limb becomes shortened, and the knee and
foot turned outwards. Ligamentous matter only is poured out
into the joint and around the head of the bone."
Richard H. Alexander.
Attended in 1797-8-9; believe the notes were taken in 1798.
From Mr. Rose, of High JVycomhe.
Dear Sir,
I am sorry to have been prevented by various engagements
attending to your request earlier, in sending you the extract from
the lecture delivered by you, on the subject of fracture of the
cervix of the os femoris, in the year 1798.
"The reason why this fracture does not unite; first, one cause
is, that the callus is effused into the cavity of the joint ; secondly,
the head of the bone cannot be kept in apposition with the cervix,
which explains why the patient is always lame."
You then related some cases published by Desault, wherein he
stated his having succeeded, and union had taken place; but as
they were in young subjects, you expressed your opinion, that
they were fractures of the trochanter, and not of the cervix.
I am, dear Sir,
Your faithful and obedient Servant,
. High Wycombe; William Rose.
Aug, SOth, 1824.
PREFACE. XVll
JVotes on Fracture of the Neck of the Thigh-Bone, taken from
Sir Astlev Cooper's Lectures in 1799, by W. Jacksoj^.
" This fracture never unites, therefore you must inform your
patients they will always be lame."
The expression of never uniting is a little too strong, for it will
be seen in my work that I have mentioned certain exceptions in
which such union might be possible ; but still, lameness is a never-
failing consequence ; it may be also stated that in addition to the
two causes of want of union which I have mentioned, there is a
third, which I have much dwelt upon in this work, viz., the supply
of blood to the head of the bone being cut off (excepting through
the medium of the ligamentum teres) by the laceration of the
reflected ligament and periosteum.
The question of union or non-union of the fracture of the neck
of the thigh-bone, as a general principle, involves very important
consequences; as the lameness which invariably follows these
accidents would expose every surgeon in the kingdom to an
action for neglect or want of skill, if such fractures would unite so
as to render the limb firm, and prevent the lameness which in
every case I ever saw was the uniform result, although union in a
large proportion of them was attempted.
If 1 were called upon to give my evidence in a court of justice
in such a case, I should say, that the lameness which was the
:*Vm PREFACE.
result was not imputable to any want of skill, but to the nature
and seat of the fracture, as I have never seen an instance in which
it did not occur. But to those who hold a contrary opinion, all
that could be said is, that you have exposed yourself to this
action from want of proper attention to the issue of these
accidents, " and out of thy own mouth shalt thou be condemned."
Since writing the above observations, I have received the
following letter and case.
Dear Sir Astley,
I beg to forward you a note of a case of fracture within the
capsular ligament, which fully illustrates your opinion of the
nature and consequences of that injury. I have abstained from
drawing any conclusions on the case, confining myself to its
history and dissection. The bones, not yet subjected to any
preparation, are in my possession, and if considered as worthy a
place in the museum, I shall feel great pleasure in forwarding
them to you.
I am, with great respect,
Sheerness ; Your obedient Servant,
Dec. Isif, 1824. Arch. Robertson.
CASE.
On the 25th of June, 1822, William Daruin, aged sixty-two, a
tall athletic convict, of a sanguine temperament, fell with a very
PREFACE. XIX
inconsiderable violence across a piece of timber in the Dock-yard,
his left hip coming in contact with the wood. On rising, he felt
an acute pain in the region of the acetabulum, but no other incon-
venience, for he walked on board to exhibit himself to the surgery
man. From finding him ranked up with the sick of the hulk on
my morning visit of the 26th, from his walking on board, and
from his own account of the accident, I did not suspect any seri-
ous injury of the joint, and treated the case as one of concussion.
On the 29th, however, he complained of a very sudden, and very
agonizing accession of pain, which induced me to subject him to a
more critical examination. No evident alteration in the size of
either hip could be discerned, but a shortening of the limb was
conspicuous, which was rendered more evident by making him
stand on the sound limb ; extension removed this difference, but
on being freed from restraint, it again assumed its morbid shape ;
the knee and foot were everted, and rotation greatly increased
his pain.
I removed him to the hospital as a case of fracture within the
capsule, but a continued attention for a period of six months to
position (chiefly with the view of restraining the motion of the
pelvis, and of securing the limb), made no other alteration in the
symptoms than a gradual diminution of pain. A pair of crutches
were given him, he was placed on the invalid list, and remained
so till the 26th of December, when he died from general dropsy.
On dissection, the injury proved a transverse fracture of the
XX PREFACE.
head of the femur within the capsular ligament. No species of
union had taken place. The upper portion of the fractured bone
was retained in situ by the sound ligament ; tolerably smooth on
its surface, but without any ossific deposit. The lower portion
very irregular, with several detached pieces of bone adhering to the
insertion of the capsular ligament. Between the acetabulum and
the portion of bone retained in situ by the ligament, several small
oval shaped loose cartilaginous substances, apparently fragments
of bone. The capsular ligament partially lacerated, in a line
above the trochanter major, and greatly thickened in its insertions.
Convict Hospital Ship, Arch. Robertson.
Sheerness, 1st Dec. 1824.
I may be permitted to add here, that I have just added to the
collection at St. Thomas's Hospital, a fracture of the patella ; in
which the portions of bone are in contact, and in which an ossific
union appeared at first sight to have been produced, and in the
living body it must have been concluded to be united ; yet the
union is only ligamentous.
A. C.
Dec. 1824.
CONTENTS.
Page,
On Dislocations in general - - - - - . 1
Particular Dislocations .--,.- 31
Dislocations of the Hip-joint - - - - - 31
Dislocation upwards, or on the Dorsum Ilii - - - 33
Dislocation downwards, or into the Foramen Ovale - - 56
Dislocation backwards, or into the Ischiatic Notch - - 68
Dislocation on the Pubes - - - - - - 82
Fractures of the Os Innominatum - - - - - 94
Fractures of the Upper Part of the Thigh-bone - - - 102
Fractures of the Neck of the Thigh-bone, within the Capsular Ligament 104
Additional Observations on Fractures of the Neck of the Thigh-bone 139
Fractures of the Cervix Femoris, external to the Capsular Ligament, and
into the Cancelli of the Trochanter Major ... 144
Fractures through the Trochanter Major . . - . 156
Fracture of the Epiphysis of the Trochanter Major - - 169
Fractures below the Trochanter - - - - - 171
Dislocations of the Knee .-.-.- 174
Dislocation of the Patella - - - - - . - 176
Dislocation of the Patella upwards - - - • ' ■> 179
Dislocation of the Tibia at the Knee-joint . - - . jgl
Partial Luxation of the Thigh-bone from the Semilunar Cartilages 186
Dislocation of the Knee-joint - . - - - ' . 190
Compound Dislocation of the Knee-joint - - ' - 191
Dislocation of the Knee from Ulceration ... - 194
Fractures of the Knee-joint - - - - - - 196
Fracture of the Patella ------ 196
Perpendicular Fracture of the Patella - - - - 205
Compound Fracture of the Patella - - , - 208
D
XXll CONTENTS.
Page.
Oblique Fractures of the Condyles of the os Fenioris into the Joint - 212
Compound Fracture of the Condyles of the Femur - . . 215
Oblique Fractures of the Os Femoris, just above its Condyles - 217
Compound Fracture, just above the Condyles of the Os Femoris <■ 219
Simple Fracture above the Condyles of the Os Femoris - - 221
Fracture of the Head of the Tibia .... . . £25
Dislocations of the Head of the Tibia - - - - 226
Dislocations of the Ancle-joint . - . . . 228
Simple Dislocation of the Tibia inwards - . . . 229
Simple Dislocation of the Tibia forwards . . - . 232
Partial Dislocation of the Tibia forwards - . . . 234
Simple Dislocation of the Tibia outwards - - - - 235
Compound Dislocation of the Ancle-joint - - - . . 237
Compound Dislocation of the Tibia inwards - - . 248
Compound Dislocation of the Tibia outwards - - . 249
On removing the Ends of the Bones - . » - 278
Additional Cases of Compound Dislocation of the Ancle-joint - 304
Cases which render Amputation necessary . . - - gjQ
Fractures of the Tibia and Fibula near the Ancle-joint - - 330
Fracture of the Tibia at the Ancle-joint - - - - 332
Dislocation of Tarsal Bones - - - - - - 334
Simple Dislocation of the Astragalus .... 334
Compound Dislocation of the Astragalus - - - - 338
Dislocation of the Os Calcis and Astragalus ... 343
Dislocation of the Os Cuneiforme Internum - . - . 354
Dislocation of the Toes from the Metatarsal-bones - - - 355
Dislocations of the Lower Jaw - - - - . 357
Complete Luxation of the Jaw . - . - . 359
Partial Dislocation of the Jaw . - - - - 362
Subluxation of the Jaw ...... 353
Dislocations of the Clavicle .-..-. 3^5
Junction of the Sternal Extremity of the Clavicle with the Sternum . 365
Dislocation of the Sternal Extremity of the Clavicle - - - 367
CONTENTS. xxiii
Page.
Junction of the Clavicle with the Scapula - - - . 372
Dislocation of the Scapular Extremity of the Clavicle - - 373
Dislocation of the Clavicle, with Fracture of the Acromion - - 376
Structure of the Shoultler-joint - - - . - 373
Dislocation of the Os Humeri - - . - . 332
Dislocation in the Axilla - - . . - - - 333
Dislocation forwards behind the Pectoral Muscle, and below the
middle of the Clavicle - - . . - - 393
Dislocation of the Os Humeri on the Dorsum Scapulae - - 403
Partial Dislocation of the Os Humeri ..... ^7
Fracture of the Neck of the Os Humeri, with the Dislocation forwards
under the Pectoral Muscle - - - . - 411
Compound Dislocation of the Os Humeri .... 422
Partial Dislocation of the Os Humeri forwards - - - 415
Dislocation of the Os Humeri backwards .... 415
Fractures near the Shoulder-joint, liable to be mistaken for Dislocations 418
Fractures of the Acromion ...... 423
Fracture of the Neck of the Scapulae - - - . . 420
Fracture of the Neck of the Os Humeri - . . - 422
Structure of the Elbow-joint ..... 425
Dislocations of the Elbow-joint - . - - . 430
Dislocation of both bones backwards - - - - - 430
Dissection of the Dislocation of the Elbow-joint - . . 431
Compound Dislocation of the Os Humeri at the Elbow-joint - 433
Lateral Dislocation of the Elbow .... - 435
Dislocation of the Ulna backwards ..... 437
Dislocation of the Radius forwards - . - - - 439
Dislocation of the Radius backwards - - - - 443
Lateral Dislocation of the Radius ..... 444
Fractures of the Elbow-joint ------ 445
Fractures above the Condyles of the Humeri - . - 445
Fracture of the Internal Condyle of the Os Humeri . - 443
Fracture of the External Condyle of the Os Humeri - - - 449
XXIV CONTENTS.
Page.
Fracture of the Coronoid Process of the Ulna - - - 451
Fracture of the Olecranon --.-.. 453
Compound Fracture of the Olecranon .... 459
Fracture of the Neck of the Radius - - - - . 459
Compound Fractures and Dislocations of the Elhow-joint - - 460
Structure of the Wrist-joint .---.- 464
Dislocations of the Wrist-joint ----- 466
Dislocation of the Radius at the Wrist - - - - 468
Dislocation of the Ulna -..--- 469
Simple Fracture of the Radius, and Dislocation of the Ulna - - 470
Fracture of the lower End of the Radius, without Dislocation of the Ulna 472
Compound Dislocation of the Ulna, with Fracture of the Radius - 473
Dislocation of the Carpal-bones . . - - . 477
Compound Dislocation of the Carpal-bones - - - . 479
Dislocation of the Metacarpal-bones ----- 482
Fracture of the Head of the Metacarpal-bones - - - 484
Dislocations of the Fingers and Toes ----- 485
Dislocation from Contraction of the Tendon - - - - 486
Dislocation of the Thumb - - - - - - 488
Dislocation of the Metacarpal-bones from the Os Trapezium - 489
Dislocation of the First Phalanx . . - - - 493
Dislocation of the Second Phalanx ----- 495
Dislocation of the Ribs ------ 497
Injuries of the Spine ------- 499
Concussion of the Spinal Marrow - - - - - 502
Extravasation in the Spinal Canal ----- 504
Fracture of the Spine ..---- 595
Fractures of the Bodies of the Vertebrae, with Displacement - 509
Inflammation and Ulceration of the Spinal Marrow - - - 517
Plates and Explanations.
TREATISE
ON
DISLOCATIONS.
DISLOCATIONS IN GENERAL.
A DISLOCATION is a displacement of the articulatory portion of a Definition.
bone from the surface on which it was naturally received.
Of the various accidents which happen to the body there are Necessity of
prompt as-
few which require more prompt assistance, or which more directly distance.
endanger the reputation of a surgeon, than cases of luxation. If
much time shall have elapsed before the attempt at reduction is
made, the difficulty of accomplishing it is proportionably increased,
and it is not unfrequently totally impracticable : and if the nature
of the injury be unknown, and the luxation consequently remain
unreduced, the patient will become a living memorial of the sur-
geon's ignorance or inattention. " What is the matter with me.^" j^fftakT **
B
j£ DISLOCATIONS IN GENERAL.
said a patient who came to my house, placing himself before me
and directing" my attention to his shoulder: "Why, Sir, your arm
is dislocated." — " Do you say so ! Mr. told me it was not
out." — " How long has it been dislocated.^" — " Many weeks," he
replied. — " Oh then you had better not have any attempt at reduc-
tion made." — He said, " Well, I will take care that Mr. has
no more bones to set ; for I will expose his ignorance in that part
of the country in which I live." — He was a man of malevolent
disposition, and carried his threat into execution, to the great
injury of the surgeon, who was also frequently reminded of his
want of skill, by meeting his former patient in his rounds ; and
what was worse, by hearing the following observation frequently
repeated : '^ Mr. is a good apothecary, but he knows
nothing of surgery."
In a dislocation of the os femoris, which still remains unreduced,
a consultation was held upon the nature of the injury, and after
a long consideration, a report was made by one of the surgeons to
this effect : " Well, Sir, thank God, we are all agreed that there
is no dislocation."
Knowledge A Considerable share of anatomical knowledge is required to
of Anatomv /» i
necessary. ' dctcct the uaturc of thcse accidents, as well as to suggest the best
means of reduction ; and it is much to be lamented, that students
neglect to inform themselves sufficiently of the structure of the
joints. They often dissect the muscles of a limb with great
neatness and minuteness, and then throw it away, without any
examination of the ligaments, cartilages, or ends of the bones ;
a knowledge of which, in a surgical point of view, is of infinitely
greater importance ; and from hence arise the errors into which
DISLOCATIONS IN GENERAL. 3
they fall when they embark in the practice of their profession;
for the dislocations of the hip, the elbow, and the shoulder, are
scarcely to be detected, but by those who possess accurate anato-
mical information. Even our hospital surgeons, who have neg-lected
their anatomy, mistake these accidents ; and I have known the
pullies applied to an hospital patient, in a case of fracture of the
neck of the thigh-bone, Avhich had been mistaken for a dislocation,
and the patient exposed, through the surgeon's ignorance, to a
violent and protracted extension. It is therefore proper, that the
form of the extremities of the bones, their mode of articula-
tion, the ligaments by which they are connected, and the direc-
tion in which their most powerful muscles act, should be well
understood.
Yet it would be an injustice not to acknowledo^e, that the Difficulty
*' *-' from tume-
tumefaction arising from extravasation of blood, and the tension f*"=''on'
resulting from the inflammation, which frequently ensues, will, in
the early days of the accident, render it difficult for the best sur-
geon to be perfectly assured of the exact extent of the injury;
and, therefore, conclusions drawn at a time when the muscles are
wasted, and the swelling is dispersed, when the head of the bone
can be distinctly felt, and the motions of the limb are found to be
impeded in a particular direction, if they tend to the prejudice of
the individual who may have given a different opinion under
circumstances so much less favourable for forming a correct con-
clusion, will be both illiberal and unjust.
The immediate effect of dislocation is to change the form of the symptoms.
joint, and often to produce an alteration in the length of the limb ;
to occasion the almost entire loss of motion in the part after the
b2
Length of
limb altered.
DISLOCATIONS IN GENERAL.
muscles have had time to contract, and to alter the axis of the
limb. This altered position of the limb has been attributed,
by some surgeons, to the influence of the remaining- portion of
ligament; but, in every accident, the direction of the bone is
too much the same to induce the belief of its being chiefly the
effect of muscular influence ; for the ligament is extensively
torn, in most cases scarcely any portion of it remaining whole,
particularly in dislocations of the thigh, yet the position of
the limb under the different species of dislocation is found sub-
ject to little variation. The form of the bone has, hoAvever,
some influence on its future position : for in fracture of the neck
of the thigh-bone, the knee is turned outwards ; whilst in disloca-
tions, it is turned inwards, a diff*erence which arises from the
greater capacity of the bone to roll upon its axis when the neck
is broken.
In the first moments, however, of the dislocation, considerable
motion remains, and the position is not so determinately fixed as it
afterwards becomes ; for I have seen a man brought into Guy's
Hospital, who, but a few minutes before, had the thigh-bone dislo-
cated into the foramen ovale, and I was surprised to find in a case
otherwise so well marked, that a great mobility of the bone still
existed at the dislocated part ; but in less than three hours, it
became firmly fixed in its new situation by the permanent, or, as
it is called, tonic contraction of the muscles.
In some dislocations the limb is rendered shorter, and thus
the muscles influenced by it are immediately thrown into a state
of relaxation ; but if the limb be elongated, the tension of the
principal muscles around the joint is extreme, and they are
DISLOCATIONS IN GENERAL. 5
sometimes stretched to laceration. Blood is often effused in EfFusion of
blood.
considerable quantity around the joint, which renders detection
of the accident difficult ; the swelling- being sometimes so con-
siderable as to conceal entirely the ends of the bones. This
effusion is in proportion to the size and number of the vessels
lacerated.
A severe but obtuse pain arises from the pressure of the head
of the bone upon the muscles, and, in some cases, this pain is ren-
dered more acute from its pressure upon a large nerve. From
this cause also is produced a paralysis of the parts below, instances
of which occur in dislocations of the shoulder. In other cases
the bone presses upon important parts, so as to produce effects Effects of
dangerous to life. I have for manv years mentioned, in my from the
° . ' . . dislocated
lectures, a case of a dislocated clavicle, pressing upon the '"'°^-
oesophagus so as to endanger life ; which Mr. Davie, of Bungay,
was so kind as to send me an account of. I shall give a more
detailed history of this case hereafter.
In most dislocations, the head of the bone may be readily felt criterion of
•' •> the accident
in its new situation; and the rotation of the limb best discovers the ''^ '^°"'''<*"-
nature of the accident, as the head of the bone can be felt to roll.
The natural prominences of the dislocated bone, in some instances,
either disappear, or become less conspicuous, as the trochanter in
luxations of the hip-joint ; but the reverse of this happens in dis-
locations of the elbow, for there the olecranon is more than usually
prominent, and serves as the principal guide for discovering the
nature of the injury.
The more remote effects of the accident are, that frequently a
sensation of crepitus is produced by the effusion of adhesive matter crepitus.
6 DISLOCATIONS IN GENERAL.
(fibrin) into the joint and biirsae; the synovia becomes inspissated,
and crackles under motion, a circumstance of which every practi-
tioner should be aware, as he may be otherwise induced erro-
neously to suspect the existence of fracture.
luflamma- 'j'jjg dcfifree of inflammation which succeeds to these accidents
tionandsup- o
puration. -^ ggjjgj.Q^ijy gUght ; but iu soiue cases it becomes so considerable
as to produce a tumefaction, which, added to that resulting- from
extravasation of blood, frequently renders the detection of the
injury exceedingly difficult. Sometimes, after the reduction of
dislocations, suppuration ensues, and the patient falls a victim to
excessive discharge and irritation. Mr. Howden, who was one
of our most intelligent apprentices at Guy's Hospital, and was
afterwards surgeon in the army, related the following case : —
"A man had his thigh dislocated upwards and backwards on
the ilium, which was soon after reduced ; the next day a consi-
derable swelling was observed on the part, which continued to
increase, accompanied with rigours, and in four days the patient
died. On dissection, the capsular ligaments, and ligamentum
teres, were found entirely torn away, and a considerable quan-
tity of pus extravasated in the surrounding parts." See Minutes
of the Physical Society, Guys Hospital, JVovember 12, 1791. —
I attended the master of a ship, who had dislocated his thigh
upwards; an extension was made, apparently, with success; but
in a few days a large abscess formed on the thigh, which
destroyed the patient : fortunately, however, such a result is by
no means common.
fidiacera- Whcu, froiu length of time, or any other circumstance, the
reduction of the limb is rendered impracticable, the bone forms for
tion of mus-
cles
DISLOCATIONS IN GENENAL. 'J
itself a new bed, and some degree of motion is gradually reco-
vered; although, in neglected dislocations of the lower extremity,
the patient is ever after lame ; and in those of the upper, the
motion and power of the limb are very much diminished.
On examination of the bodies of persons who die in conse- Appearances
quence of dislocations arising from violence, the head of the bone
is found completely removed from its socket. The capsular liga-
ment is torn transversely to a great extent; the peculiar ligaments Ligaments.
of joints, as the ligamentum teres of the hip, are torn through ;
but the tendon of the biceps, in dislocations of the os humeri,
remains uninjured, as far as I have been able to ascertain by dis-
section ; although I should be sorry to be understood to say that
this is universally the case.
The tendons which cover the ligaments are also torn; as the Tendons.
tendon of the sub-scapularis muscle, in the dislocation in the
axilla; and according to the extent of this laceration, is the facility
with which the accident recurs after reduction ; a circumstance
frequently very difficult to obviate.
The muscles also are influenced by the nature of the accident, Muscles.
being in some cases put upon the stretch, even to laceration ; as
the pectineus and abductor brevis, in dislocation of the thigh
downward ; and large quantities of blood become extravasated
into the cellular membrane.
The appearance of ioints which have Ions: been dislocated. Dissections
^^ •' ^ ^ of old dislo-
depends not only on the length of time that has elapsed from the «'"'0"s-
accident, but also on the structure upon which the head of the
dislocated bone is thrown ; for if it be found embedded in muscle, Sfne'^embed!
its articular cartilage remains, and a new capsular ligament lorms cie.
8 DISLOCATIONS IN GENERAL.
Manner of
its forma-
tion.
Formation arouiicl it, which does not adhere to its cartilaginous surface.
of a new ^
iT-amlnt This ligament, in dislocations of the femur, contains within it the
head of the bone, with the lacerated portion of the ligamentum
teres united to it, (^See plate) In these instances the bones them-
selves underg^o little change. The capsular ligament is formed
from the surrounding cellular tissue; which, being pressed upon by
the head of the bone, becomes inflamed, thickened, and condensed.
By this means a substance is produced somewhat less dense than
original ligament, but still possessing sufficient firmness to bear
considerable pressure, and to furnish some degree of support.
Head of the But if thc head of the dislocated bone be placed on the surface
bone resting'
bonT*''" of another bone, or upon a thin muscle over it, that muscle becomes
absorbed, and the bone undergoes a remarkable change ; thus it
is found, if the dislocation be not reduced, that both the ball and
the bone which receives it are changed in their form. The pres-
sure of the head of the bone produces absorption of the periosteum,
and of the articular cartilaginous surface of the head of the bone;
a smooth hollow surface is formed, and the ball becomes altered
in its shape to adapt it to its new surface ; and whilst this absorp-
tion proceeds upon the part on which the head of the bone rests,
an ossific deposit takes place around it from the periosteum, which
is there irritated but not absorbed. By the deposition of this
bony matter between the periosteum and the original bone, a deep
Foimationof cup is formcd to Tcceive the head of the bone ; and perhaps no
a new socket. •• ■••■•■
instances can be adduced which more strongly mark the powers
of nature in changing the form of parts to accommodate them to
new circumstances, than these effects of dislocation. (^See plates
2, 3 and 4.)
DISLOCATIONS IN GENERAL. 9
The new cup which is thus formed, sometimes so completely
surrounds the neck of the bone, as to prevent its being removed
from it without fracture (see plate); and the socket is smoothed
upon its internal surface, so as to leave no projecting parts which
can interrupt the motion of the bone in its new situation.
The muscles losing their action, become diminished in bulk, and
reduced in their length, in proportion to the displacement of the
bone towards their origin ; and if the dislocation has been long
unreduced, they lose their flexibility, and tear rather than yield to
extension.
Dislocations
from
Although dislocations happening from violence are accompanied
by laceration of the ligaments of the joint, yet they may occur relaxation.
from relaxation of the ligaments only, of which the following case
is an example.
CASE.
A girl came to my house, Avho had the power of throwing her case.
patellse from the surfaces of the condyles of the os femoris. Her
knees were bent considerably inwards; and when the rectus muscle
acted upon the patella, it was drawn from the thigh-bone into a line
with the tubercle of the tibia, and laid nearly flat upon the side of
the external condyle of the femur. She came from the south of
Europe, and said she had been brought up as a dancing girl from
her earliest years, thus, gaining her daily bread, as we see children
dancing upon elevated platforms in the streets of London; and
10 DISLOCATIONS IN GENERAL.
she imputed to these continued and early exertions the weakness
under which she laboured.
Dislocation
from accu-
mulation of
synovia.
A similar relaxation of ligaments, is also produced by an accu-
mulation of synovia in joints. Mr. Shillito, surgeon at Hertford,
requested me to see the servant of a gentleman in my neighbour-
hood, who had a great enlargement of the knee-joint from an
inordinate secretion of synovia ; and when this became absorbed,
the ligaments remained so much relaxed, that the efforts of the
muscles in walking dislocated the patella outwards. 1 ordered her
into the hospital, that the students might observe this case, of
which the following is an account.
CASE.
Dislocation Auu Parisli was admitted into Guy's Hospital in tlie autumn of
trnm relaxa- * ■•-
1810, for a dislocation of the left patella from relaxation of the
ligaments. She had for four years previously a large accumulation
of synovia in that knee, causing some pain, and much inconveni-
ence in walking. Blisters had been applied without much effect,
and other means tried, for four months before her admission.
When the knee had acquired considerable size, the swelling spon-
taneously subsided, and she then first discovered that the patella
became dislocated when she extended the limb. She suffered some
pain whenever this happened, and she lost the power of the limb
in walking, so that she fell when the patella slipped from its place,
which it did whenever she attempted to walk without a bandage.
The patella was placed upon the external condyle of the os femoris,
when thrown from its natural situation, to which it did not return
from relaxa
tion
DISLOCATIONS IN GENERAL. 11
without considerable pressure of the hand. In other respects her
health was good. Straps of adhesive plaster were ordered to be
applied, and a roller to be worn, which succeeded in preventing
the dislocation so long as they were used, but the bone again
slipped from its place whenever they were removed. A knee-cap,
made to lace over the joint, was ordered for her.
Dislocation sometimes arise from a loss of muscular power ; Paralysis.
for when the muscles are kept long and forciby extended, their
tone becomes destroyed ; or if, from a paralytic affection, they lose
their action, a bone may be dislocated easily, but is as readily
replaced : of the first of these two causes, the following case is an
illustration.
CASE.
Mr. , a gentleman, now residing in the City, whilst in the
East Indies, as a junior officer on board his ship, had been placed
under the orders of one of the mates when the captain was on shore,
and for some trifling oifence this young gentleman was punished
in the following manner : — His foot was placed upon a small pro-
jection on the deck, and his arm was lashed tightly towards the
yard of the ship, and thus kept extended for an hour. When he
returned to England, he had the power of readily throwing that
arm from its socket, merely by raising it towards his head ; but a
very slight extension reduced it ; the muscles were also wasted, as
in a case of paralysis. A prosecution was commenced for this act
of cruelty, and I was subpoenaed to give evidence ; but the petty
c2
12 DISLOCATIONS IN GENERilL.
tyrant chose to pay the forfeit of his misconduct prior to the
commencement of the trial.
I have also seen in a dislocation of the thumb, the first phalanx
capable of being thrown from the os metacarpi pollicis, merely by
the action of the muscles, from a relaxed state of the ligament.
Of the influence of paralysis, the following- case is an example :
CASE.
I was desired to see a young gentleman, who had one of those
paralytic affections in his right side which frequently arise during
dentition. The muscles of the shoulder were wasted ; and he had
the power of throwing his os humeri over the posterior edge of
the glenoid cavity of the scapula, from whence it became easily
reduced.
In these cases, particularly in the latter, no laceration of the
ligaments could have occurred ; and they shew the influence of
the muscles in preventing dislocation from violence, and in im-
peding its reduction.
Dislocation
from ulcera-.
tion.
Dislocations arise from ulceration, by which the ligaments are
detached, and the bones become altered in their form. We fre-
quently find this state of parts in the hip-joint; the ligaments
ulcerated, the edge of the acetabulum absorbed, the head of the
thigh-bone changed both in its magnitude and figure, escaping
from the acetabulum upon the ilium, and there forming for itself
DISLOCATIONS IN GENERAL. 13
a new socket. We have in the anatomical collection at St.
Thomas's Hospital, a preparation of the knee dislocated by ulce-
ration, anchylosed at right angles with the femur, and the tibia
turned directly forwards. A boy, in Guy's Hospital, had his knee
dislocated by ulceration, whose tibia was thrown on the inner side
of the external condyle of the os femoris ; and a girl, in the same
hospital, had the knee dislocated by ulceration, the head of the
tibia being placed behind the condyles of the os femoris.
Dislocations are sometimes accompanied with fracture. At the Fracture and
'^ dislocation.
ancle joint it rarely happens that dislocation occurs without a
fracture of the fibula, and at the hij)-joint the acetabulum is
occasionally broken : — of this an example will be seen in the
following
CASE.
Thomas Steers was admitted into Guy's Hospital, on the 28th Dislocation
of October, 1805, with a dislocation of the os femoris into the ksion!'^^*"''
ischiatic notch. The dislocation was reduced by a very slight
extension, compared with that which is commonly required; this
was imputed to the muscular relaxation caused by nausea, the
patient having vomited at the time of his admission. But he soon
complained of severe pain, extending over his abdomen, and he
died on the day following his admission. Upon inspecting his
body, the intestinum jejunum was found ruptured ; and upon
examination of the hip-joint, a portion of the edge of the aceta-
bulum was discovered to be broken off.
14
DISLOCATIONS IN GENERAL.
Dislocation
and fracture,
Dislocations of the os humeri are also sometimes accompanied
with fracture of the head of that bone, of which we have a
specimen in the Museum at St. Thomas's Hospital. The coronoid
process is sometimes broken in dislocations of the ulna, producing
a species of luxation, which does not admit of the bone being
afterwards preserved in its natural situation.
When a bone is both broken and dislocated, it is proper to
endeavour to reduce the dislocation without loss of time, taking"
care that the fractured part be strongly bandaged in splints, to
prevent any injury to the muscles ; for if this be not done at first,
it cannot be afterwards effected without danger of re-producing
the fracture.
If a compound fracture of the leg, and a dislocation of the
shoulder, happen in an individual at the same time, the reduction
of the arm should be immediately undertaken, after the fractured
limb has been secured in splints. The Rev. Mr. H , owing to
his being thrown from his chaise, had a compound fracture of the
leg, and a dislocation of the shoulder forwards. The dislocation
was not at first observed, nor was its reduction attempted till a
fortnight after the accident. The trial proved unsuccessful, as,
from a dread of fever and of injury to the leg, sufficient extension
could not be used.
The accidents which have been called dislocations of the spine,
are generally fractures of the vertebrae, followed by displacement
of the bones, but not of the intervertebral substance ; and even
the articulatory processes are broken, as well as the bodies of the
vertebrae, so that they are not true dislocations of the spine,
excepting those of the upper cervical vertebrae, dislocations of
DISLOCATIONS IN GENERAL. 15
which are said to have occasionally occurred. The injuries of the
spine, which produce paralysis of the lower extremities, are frac-
tures of the bodies of the vertebrae, pressing upon, and sometimes
lacerating', the medulla spinalis.
In compound dislocation, not only the articulatorv surfaces ^?'?p«>™''
-t •' .' Dislocations
of the bone are displaced, but the cavity of the joint is laid open
by a division of the skin and the capsular ligament. The imme-
diate effect of compound dislocation is, to occasion the extrava-
sation of blood into the joint, and to allow the escape of the
synovia.
Compound dislocations are attended with great danger, and for Danger.
the following reason:
When a joint is opened, inflammation of the lacerated ligaments
and synovial surface speedily succeeds ; in a few hours suppuration
begins, and granulations arise from the surface of the secreting
membrane; which, being of the mucous kind, is more disposed to
the suppurative, than to the adhesive inflammation. But the same
process does not immediately ensue upon the extremity of the bone^
because it is covered by the articular cartilage. This cartilage,
before the cavity fills with granulations, becomes absorbed, by an
ulcerative process instituted on the end of the bones, but sometimes
beginning from the synovial surface. The bone inflames, the
cartilage becomes ulcerated, numerous abscesses are formed in
different parts of the joint, and at length granulations spring from
the extremities of the bones deprived of their cartilages, and fill
up the cavity; generally these granulations become ossified, and
anchylosis succeeds ; but sometimes they remain of a softer texture,
and some degree of motion in the joint is gradually regained.
16 DISLOCATIONS IN GENERAL.
This process of filling up joints requires great general, as well
as local efforts ; a high degree of irritation is produced ; and if
the constitution be weak, the patient, to preserve his life, is
sometimes obliged to submit to amputation.
, . In addition to the above circumstances, the violence necessarily
Injury to ^ J
biTOd-^ves- inflicted on the parts, in compound dislocations, the injury which
the muscles and tendons sustain, and the laceration of blood-
vessels, necessarily lead to more important and dangerous conse-
quences than those which follow simple dislocations.
With respect to the treatment of compound dislocations, it is
not my intention, in this part of the work to describe it, but to
reserve what I have to say on that subject for the description of
compound dislocations of the ancle, where such observations will
be required, and where they will be better understood ; and thus a
repetition, which would be both irksome and useless to the reader,
will be avoided. I shall just remark, that some joints are more
liable to compound dislocations than others. The hip-joint is
scarcely ever so dislocated ; of the shoulder I have known two
instances ; but the elbow, wrist, ancle, and fingers, are frequently
the seats of this accident ; and I have seen an instance of it at
the knee.
Some joints In cousequeuce of their different formation, we find that in some
more easily ., ,.,.. , ^ I'l tt\\
dislocated joints, dislocatiou IS much more frequent than in others. Ihose
than others. '' ^
which have naturally extensive motions are easily luxated, and
hence the dislocation of the os humeri occurs much more fre-
quently than that of any other bone ; and having once occurred, it
happens again easily in the mere natural elevation of the arm. It
is wisely ordained, that in those parts to which extensive motion is
DISLOCATIONS IN GENERAL. 17
assigned, and for which g-reat strength is required, there is a mul-
tiplicity of joints. Thus, in the spine, in which great strength is
necessary to protect the spinal marrow, numerous joints are formed,
and the motion between any two bones is so small, that dislo-
cations, except between the first and second vertebrae, rarely
occur, although the bones are often displaced by fracture.
The carpus and the tarsus are constituted on a similar prin-
ciple ; they allow of considerable motion, yet maintain great
strength of union. For if the motion between two bones, as in
the spine, be multiplied by twenty-four, and that at the carpus by
eight, the result will shew that great latitude of motion is given,
and the strength of the part preserved ; whilst, if the spine had
been formed of a single joint, dislocations might have easily
happened, and death from this cause might have been a frequent
consequence.
Dislocations are not always complete, since bones are sometimes Partial dis-
•^ locations.
but partially thrown from the articulatory surface on which they
rested : this species of dislocation now and then occurs at the
ancle-joint. An ancle was dissected at Guy's, by JMr. Tyrrell, and instance.
given to the collection of St. Thomas's, which was partially
dislocated ; the end of the tibia still rested in part upon the
astragalus, but a larger portion of its surface on the os navi-
culare, and the tibia, altered by this change of place, had formed
two new articulatory surfaces, with their faces turned in opposite
directions towards the two tarsal bones. (^See plate.^ The dislo-
cation had not been reduced. The knee-joint is, I believe, rarely
dislocated laterally in any other way ; for its extensive articular
surfaces almost preclude the possibility of complete displacement.
D
18 DISLOCATIONS IN GENERAL.
The OS humeri sometimes rests upon the edge of the glenoid
cavity, and readily returns into its socket ; and the elbow-joint is
dislocated partially, both in relation to the ulna and the radius.
The lower jaw is also sometimes partially dislocated, but in a
different manner ; one of the joints being luxated, and the other
remaining in its place.
Cause. Dislocations are generally occasioned by violence, and the force
is usually applied whilst the bone is in an oblique direction to its
socket ; but it is necessary that the muscles should be in a great
degree unprepared for resistance, otherwise the greatest force will
hardly produce the effect : when they are unprepared, it will often
ensue from very slight accidents. A fall, in walking, will some-
times dislocate the hip-joint, when the muscles have been prepared
for a different exertion.
While dwelling on this subject in my lectures, I have usually
adverted to the execution of Damien, as illustrative of this
position.
Resistance Damicu was cxccutcd for the attempt to murder Lewis XV.
Four young horses were fixed to his legs and arms, and were
forced to make repeated efforts to tear his limbs from his body,
but could not effect this purpose; and after fifty minutes, the
executioners were obliged to cut the muscles and ligaments to
effect his dismemberment.
The following is the French account of this execution :
" II arriva a la place de Greve a trois heures et un quart,
regardant d'un ceil sec et ferme le lieu, et les instrumens de son
supplice. On lui brula d'abord la main droite ; ensuite on le
tenailla, et on versa sur ses plaies, de I'huile, du plomb fondu, et
of the mus-
cles
DISLOCATIONS IN GENERAL. 19
de la poix-resine. On proceda ensuite a recartellement. Les qiiatre
chevaiix firent pendant cinquante minutes des efforts inutiles pour
demembrer ce monstre. Au bout de ce terns la, Damien, etant
encore plein de vie, les bourreaux lui couperent avec de bistouris,
les chairs et les jointures nerveuses des cuisses, et des bras ; ce
qu'on avoit ete oblige de faire en 1610 pour Ravaillac. II respiroit
encore apres que les cuisses furent coupees, et il ne rendit I'ame
que pendant qu'on lui coupoit les bras. Son supplice depuis
I'instant qu'il fut mis sur I'echafaud, jusqu' au moment de sa mort,
dura pres d'une heure et demie. II conserva toute sa connoissance,
et releva sa tete sept ou huit fois, pour regarder les chevaux, et
ses membres tenailles et brules. Au milieu des tourmens les plus
affreux de la question il avoit laisse echapper des plaisanteries. —
Dictionnaire Historique"
Old persons are much less liable to dislocations than those of Dislocations
middle life, because the extremities of bones in advanced age are persons,
often so soft as to break under the force applied, rather than quit
their natural situations. Persons of lax fibre are prone to disloca-
tion, because their ligaments easily tear, and their muscles possess
little power of resistance. From these circumstances old people
would be exposed to frequent dislocations, but for the softened
state of the extremities of their bones.
Young persons are also very rarely the subjects of dislocations Dislocations
- . rare in the
from violence ; but now and then such accidents do occur ; or young^.
which I have described an instance in a child at seven years of
age. It generally happens that their bones break, or their epi-
physes give way, rather than that the parts displace. I read of
dislocations of the hip in children, but their history is that of
D 2
20 _ DISLOCATIONS IN GENERAL.
diseases of the hip-joint, in which the dislocation arises from
ulceration. A child was brought to me from one of the coun-
ties north of London, who had repeated extensions made by one
of those people called bone-setters, — but who oug-ht rather to be
called dislocators, — for a supposed dislocation of the hip-joint.
Uj)on examination, I found the case to be that disease of the hip
which is so common in children ; and for this only, was a child
wantonly exposed to a most painful extension. That in this
enlightened country, men, without education, should be suffered
with impunity to degrade a most useful profession, and put to
the torture those Avho have the folly to apply to them, is a dis-
grace to our laws, that calls loudly for prevention.
Elbow-joint Dislocations of the elbow-joint in children are said to be of
dislocations.
frequent occurrence. Surgeons have been heard to say, " I have
a child under my care with luxation of its elbow, and I can easily
return the bone into its place, but it directly dislocates again."
Such a case is, in reality, an oblique fracture of the condyles of
the OS humeri, which produces the appearance of dislocation, by
allowing the radius and ulna, or the ulna alone, to be drawn back
with the fractured condyle, so as to produce considerable projec-
tion at the posterior part of the joint.
TREATMENT.
Reduction. '^^^^ rcductiou of dislocatious is often difficult ; and in some of
the joints, the form of the bone may occasion impediments. Thus,
when the socket is surrounded by a lip of bone, as in the hip-
joint, the head of the bone, during the act of reduction, stops at
Difficulty in this projection, and requires to be lifted over it; another difficulty
DISLOCATIONS IN GENERAL. 21
occurs wben the head of the bone is much larger than its cervix,
as for example, in the dislocation of the head of the radius ; but
still these causes are slig-ht in comparison with others which we
have to detail.
The capsular ligaments are supposed to resist reduction ; but xhecapsuiar
those who entertain that opinion must forget their inelastic struc- '°'""^" ^*
ture, and cannot have had opportunities of witnessing, by dissec-
tion, the extensive laceration which they sustain in dislocations
from violence. The capsular ligaments, in truth, possess but little
strength either to prevent dislocation, or to resist the means of
reduction ; and if the tendons with which they are covered, and
the peculiar ligaments of the joints did not exist, dislocation must
be of very frequent occurrence.
The joint of the shoulder, and those of the knee and elbow, are Tendons.
strongly protected by tendons ; the shoulder by those of the spi-
nati, sub-scapularis, and teres minor muscles ; the elbow by the
triceps and brachialis ; the knee by the tendinous expansion of the
vasti; but still some ligaments resist dislocations ; these, however,
are the peculiar, not the capsular lisfaments. The wrist and the Peculiar
*■ 1 o ligaments.
elbow have their appropriate lateral ligaments to give additional
strength to these joints. The shoulder, instead of a peculiar liga-
ment, has the tendon of the biceps received into it, which lessens
the tendency to dislocation forwards ; the ligamentum teres of the
hip-joint prevents a ready dislocation downwards ; the knee has its
lateral and crucial ligaments ; and the ancle, exposed as it is to
the most severe injuries, is provided with its deltoid and fibular
tarsal ligaments, of very extraordinary strength, to prevent dislo-
cation. The bones of this joint often break rather than their
22 DISLOCATIONS IN GENERAL.
ligaments give way ; however, in many of the joints, as these liga-
ments are torn, they afford no resistance to the reduction of dis-
locations, as in the hip, elbow, and wrist; but if one of them
remain, it produces difficulty in the reduction, as I have seen in
the knee-joint.
The difficulty in reducing dislocations arises principally from
Muscles. ^\^Q resistance which the muscles present by their contraction, and
which is proportioned to the length of time which has elapsed
from the injury ; it is therefore desirable that the attempt at
reduction should not be long delayed.
The common actions of the muscles are voluntary or invo-
luntary, but they have a power of contraction independent of
either state.
Fatigue of A musclc, whcu cxcitcd to action by volition, soon becomes
fatigued, and requires rest. The arm can be extended only for a
few minutes, at right angles with the body, before it feels a fatigue
which requires suspension of action ; and, indeed, the same law
governs involuntary action, as the heart has its contraction and
relaxation.
Permanent But whcu a musclc is dividcd, its parts contract ; or when the
antagonist muscle is cut, the undivided muscle draws the parts
into which it is inserted, into a fixed situation. Thus, if the
biceps muscle be divided, the triceps keeps the arm constantly
extended; if the muscles on one side of the face are paralytic,
the opposing muscles draw the face to their side. This contraction
is not succeeded by fatigue or relaxation, but will continue an
indefinite time, even until the structure of the muscle becomes
changed ; and its contraction increases from the first occurrence
muscles.
contraction.
DISLOCATIONS IN GENERAL. 23
of the accident. Thus it is, that when a hone is dislocated, the
muscles draw it as far from the joint as the surrounding parts
will allow, and there by their contraction they fix it. It is this
resistance from muscles, aided by their voluntary contraction,
which the surgeon is required to counteract. If an extension be
made almost immediately after a dislocation has happened, the
resistance produced by the muscles is easily overcome : but if the
operation be postponed for a few days only, the utmost difficulty
occurs in effecting it.
Mr. Forster, son of the surgeon of Guy's Hospital, informed me, ^„sc£*'^''^
that in a fatal case of fracture of the thigh-bone, which he had
an opportunity of dissecting before its union, the ends of the bones
overlapped, and the muscles had acquired a contraction so rigid,
that he could not, even in the dead body, bring the bones to their
natural position, after employing all the force he was capable of
exerting ; and it is this state of muscles in dislocations, which
gives rise to the difficulty in their reduction ; and which, even in
the dead body, is still capable of opposing a very considerable
resistance.
That the muscles are the chief cause of resistance, is strongly
evinced by those cases in which the dislocation is accompanied by
injury to any vital organ, and when the power of muscular action
is diminished; for it is then found, that a very slight force is suffi-
cient to return the bone to its situation. Thus, in the case already
mentioned, of the man who had an injury to his jejunum, and a
dislocation of his hip, the bone was restored to its place with little
difficulty.
•' • • r Other diffi-
When a dislocation has long existed, difficulties arise irom cuuies.
24 DISLOCATIONS IN GENERAL.
three other circumstances. The extremity of the bone contracts
adhesion to the surrounding parts, so that even when in dissection
the muscles are removed, the bone cannot be reduced. In this
state I found the head of a radius, which had been long- dislocated
upon the external condyle of the os humeri, and which is preserved
in the collection at St. Thomas's Hospital (see plate); and in
a similar state I have seen the os humeri when dislocated. The
socket is also sometimes so filled with adhesive matter, that if the
bone was reduced, it could not remain in its original situation,
and the original cavity is in part filled with ossific matter, so as to
render it incapable of receiving the head of the bone. Lastly :
a new bony socket is sometimes formed, in which the head of the
bone is so completely confined, that nothing but its fracture will
allow it to escape from its new situation. {See plate.^
Means of Thc mcaus to be employed for the reduction of dislocations,
are both constitutional and mechanical ; it is generally wrong to
employ force only, since it would be required in so great a
degree as to occasion violence and injury ; and it will in the
sequel be shewn, that the most powerful mechanical means fail
when unaided by constitutional remedies. The power and direc-
tion of the larger muscles are, in the first instance, to be duly
appreciated, as these form the principal causes of resistance.
The constitutional means to be employed for the purpose of
reduction are those which produce a tendency to syncope, and
this necessary state may be best induced by one or other of
the following means, viz. : bleeding, warm bath, and nausea.
Of these remedies, I consider bleeding the most powerful ; and,
that the effect may be produced as quickly as possible, the blood
Constitu-
tional.
DISLOCATIONS IN GENERAL. 25
should be drawn from a large orifice, and the patient kept in the
erect position, for by this mode of depletion, syncope is produced
before too large a quantity of blood is lost. However, the activity
of this practice must be regulated by the constitution of the
patient ; if he be young, athletic, and muscular, the quantity
removed should be considerable, and the method of taking it
away should be that which I have described.
Secondly ; in those cases in which the Avarm bath may be
thought preferable, or where it may be considered improper to
continue the bleeding, the bath should be employed at the tempe-
rature of 100° to 110°; and, as the object is the same as in
bleeding, the person should be kept in the bath at the same heat
till the fainting effect is produced, when he should be immediately
placed in a chair, wrapped in a blanket, and the mechanical
means employed which I shall hereafter particularly describe.
Of late years, I have practised a third mode of lowering the
action of the muscles, by exhibiting nauseating doses of tartarized
antimony ; but as its action is uncertain, frequently producing
vomiting, which is unnecessary, I rather recommend its application
merely to keep up the state of syncope already produced by the
two preceding means ; which its nauseating effects will most
readily do, and so powerfully overcome the tone of the muscles,
that dislocations may be reduced with much less effort, and at a
much more distant period from the accident, than can be effected
in any other way.
The two cases related in the following pages, one from Mr.
Norwood, surgeon, at Hertford, and the other from Mr. Thomas,
apothecary to St. Luke's Hospital, will illustrate the efficacy of
26 DISLOCATIONS IN GENERAL.
the treatment recommended. By the comhination of bleeding,
the warm bath, and nauseating doses of tartarized antimony, two
dislocations were reduced at a more distant period from the
accident than I have ever known in any other example. One of
these cases occurred at Guy's, and the other at St. Thomas's
Hospital, at the time when these gentlemen were officiating as
dressers. (^See cases of dislocation on the ilium.)
Opium. The effect of opium I have never tried, but it would probably
be useful in a large dose, from its power of diminishing muscular
and nervous influence.
Mechanical Tlic reductiou of the bone is to be attempted, after lessening
the powers of the muscles, by fixing one bone, and drawing the
other towards its socket. It is now generally agreed among the
Force gra- most eminent surgeons, that force should be only gradually
applied ; for violence is as likely to tear sound parts, as to reduce
those which are luxated ; and it is apt to excite all the powers of
resistance to oppose the efforts of the surgeon. But it is his
duty to produce, gradually, that state of fatigue and relaxation
which is sure to follow continued extension, and not to attempt at
once to overpower the action of the muscles.
One great cause of failure in the attempt to reduce dislocations,
arises from insufficient attention to fixing that bone in which the
socket is placed. As for example : in attempting to reduce a dis-
location of the shoulder, if the scapula be not fixed, or one person
pull at the scapula and two at the arm, the scapula will be neces-
sarily drawn with the os humeri, and the extension will be very
imperfectly made; the one bone, therefore, must be firmly fixed,
or drawn in the opposite direction, whilst the other is extended.
means
dual
DISLOCATIONS IN GENERAL. 27
The force required, may be applied either by the exertion of compound
assistants, or by a compound pulley ; but the object is to extend
the muscles by gradual, regular, and continued efforts ; the pulley,
in cases of difficulty, should ahvays be resorted to; its effect may
be gentle, continued, and directed by the surgeon's mind; but
when assistants are employed, their exertions are sudden, violent,
and often ill-directed; and the force is more likely to produce
laceration of parts, than to restore the bone to its situation.
Their efforts are also frequently uncombined, and their muscles
as necessarily fatigue, as those of the patient, whose resistance
they are employed to overcome.
In dislocation of the hip-joint, pullies should always be em-
ployed ; and in those dislocations of the shoulder which have
long remained unreduced, they should also be resorted to. I do
not mean to doubt the possibility of reducing dislocations of the
hip by the aid of men only, but to point out the inferiority of this
mode to the pullies. The employment of pullies in dislocations,
is not a modern practice ; Ambrose Pare was in the habit of
employing pullies, and good practical surgeons have used them
since his time ; — and most writers on surgery have mentioned
their use, but they have not duly appreciated them. Mr. Cline,
whose professional judgment every one must acknowledge,
always strongly recommended them.
During the attempt to reduce luxations, the surgeon should Relaxation
endeavour to obtain a relaxation of the stronger opposing muscles, er muscles.
The limb should therefore be kept in a position between flexion
and extension, as far as it can be obtained. Who has not seen,
in the attempt to reduce a compound fracture in the extended
E 2
extension
should be
applied to
the disloca-
ted bone.
28 DISLOCATIONS IN GENERAL.
position of a limb, the bone, which could not be brought into
apposition under the most violent efforts, quickly replaced by an
intelligent surgeon, who has directed the limb to be bent, and the
muscles to be placed in a comparative state of relaxation?
Whether the ^ differcucc of opiniou prevails, whether it is best to apply
the extension on the dislocated bone, or on the limb below.
M. Boyer, who has long taken the lead in surgery in Paris,
prefers the latter mode. As far as I have had an opportunity
of observing, it is generally best to apply the extension to the
bone which is dislocated. There are, however, exceptions to this
rule in the dislocation of the shoulder, which I generally reduce
by placing the heel in the axilla, and by drawing the arm at the
wrist in a line with the side of the body.
Influence of In thc rcduction of dislocations, great advantage is derived from
attending to the patient's mind ; the muscles opposing the efforts
of the surgeon, by acting in obedience to the will, may have that
action suspended, by directing the mind to other muscles. Several
years since, a surgeon in Blackfriars' Road, asked me to see a
patient of his with a dislocated shoulder, which had resisted the
various attempts he had made at reduction. I found the patient
in bed, with his right arm dislocated ; I sat down on the bed by
his side, placed my heel in the axilla, and drew the arm at the
wrist ; the dislocated bone remained unmoved. I said, " Rise
from your bed. Sir;" he made an effort to do so, whilst I con-
tinued my extension, and the bone snapped into its socket ; for a
similar reason, a slight effort, when the muscles are unprepared,
Avill succeed in the reduction of dislocation, after violent measures
have failed.
the mind.
DISLOCATIONS IN GENERAL. 29
The reduction of the limb is known to have been effected by
the restoration of its natural form, the recovery of its original
motion, and by a snap, which is heard when the bone returns
into its articulatory cavity.
When a bone has been redjiced by the pullies, it will not
remain in its situation without the aid of bandages to support
it till muscular action returns. In the hip, however, dislocation second dis-
location.
rarely occurs a second time, but the shoulder and the lower jaw
very frequently slip again from their sockets, owing to the little
depth of the cavity into which the head of the bone is received ;
and, therefore, they require bandages for a considerable period
subsequent to reduction.
Rest is necessary for some time after the reduction of the limb, Rest of the
in order to produce an union of the ruptured ligament, which
would be prevented by exercise. The strength of the muscles and
ligaments may also be greatly promoted by pouring cold water
upon the limb, and by the subsequent employment of friction.
I believe that much mischief is produced by attempts to reduce q,j jisj,,^^.
dislocations of long standing in very muscular persons. I have bered"ced/
seen great contusion of the integuments, laceration and bruises
of muscles, tension of nerves, leading to an insensibility and
paralysis of the hand, occasioned by an abortive attempt to reduce
a dislocation of the shoulder ; so that the patient's condition has
been rendered much worse than before. In such cases, even
when the bone is replaced, it is often rather an evil than a good,
from the violence of the extension.
In those instances, in which the bone remains in the axilla,
in dislocations of the shoulder, a serviceable limb, and very
30 DISLOCATIONS IN GENERAL.
extensive motions of it may be regained, although reduction has
not been effected. Captain S — , who dislocated his shoulder
four years ago, called to shew me how much motion he had
recovered, although the arm still remained unreduced.
Time for at- I am of opiniou, that three months after the accident for the
tempting re- *
auction. shoulder, and eight weeks for the hip, may be fixed as the period
at which it would be imprudent to make the attempt at reduction,
except in persons of extremely relaxed fibre, or of advanced age.
At the same time, I am fully aware, that the shoulder has been
reduced at a more distant period than that which I have men-
tioned, but, in most instances, with the results I have just been
deprecating.
In cases of unreduced dislocation, the only course which the
surgeon can adopt, after the inflammation which the injury pro-
duces has subsided, is, to advise motion of the limb, and friction
of the injured part : — The former, to produce a new cavity for
the head of the bone, to assist in forming a new ligament,
and in restoring action to muscles, which would otherwise lose
it by repose ; — the latter, to promote absorption, and remove the
swelling and adhesions which the accident has produced.
PARTICULAR DISLOCATIONS.
DISLOCATIONS OF THE HIP-JOINT.
The acetabulum of the hip-joint is deepened by a cartilaginous Anatomy of
ridge, which surrounds its brim ; and although in the skeleton it
is not a complete cup, yet it is rendered such in the living subject,
by an additional portion of cartilage, which fills up a depression in
the bone in the inferior and anterior part of the cavity.
The ligaments are two : the capsular arises from the edge of ^'g^™^"*^-
the acetabulum, and passing over the head and neck of the bone,
is inserted into the cervix of the os femoris at the root of the tro-
chanter major. It is much more extensive upon the anterior than
on the posterior portion of the neck of the bone. The inner side
of this ligament is a secreting surface, producing the synovia ; and
a reflected portion of it towards the head of the bone is also pro-
vided with a similar secreting surface.
On the anterior surface of the neck of the thigh-bone, the cap-
sular ligament is received into a line, which extends from the
32
PARTICULAR DISLOCATIOIVS.
trochanter major to the trochanter minor. The synovial secreting
surface is reflected towards the head of the hone, and the ligament
is reflected close on the neck of the bone, to form the periosteum ;
whilst its fibres are blended in with the common periosteum, below
the insertion of the lig-ament, into the bone.
On the posterior surface the capsular ligament is received upon
the neck of the bone, nearly midway between the edge of the
head of the bone and the trochanter major. The common peri-
osteum on the neck of the bone blends in with the reflected liga-
ment, to form the periosteum of the neck of the bone within the
capsule.*
The ligamentum teres is contained within the capsular ligament,
and proceeds from a depression in the lower and inner part of the
acetabulum, to be fixed in a hollow upon the inner side of the
thigh-bone : it has a tendency to prevent dislocations in all direc-
tions, but particularly the dislocation downwards ; for when this
dislocation occurs, the thighs are widely separated from each
other, as in fencing ; and the head of the thigh-bone would be in
danger of slipping from its socket, but that this ligament prevents
it; — an example of its use, which shews the principal reason of
its formation.
Modeofdis- The thiffh-bone I have seen dislocated in four directions: —
location. *-'
First, upwards, or upon the dorsum of the ilium. Secondly,
downwards, or into the foramen ovale. Thirdly, backwards.
* Query. — Can this ligamentous periosteum be one cause of a ligamentous union in fractures
within the joints ? I believe that when an union of the neck of the thigh-bone is met with, it will be in
a case in which this ligamentous sheath of the cervix is not torn. (See plate XIII Jig. 3. J
PARTICULAR DISLOCATIONS. 33
and upwards, or into the ischiatic notch ; and. Fourthly, forwards,
and upwards, or upon the body of the pubes. A dislocation down-
wards and backwards, has been described by some surgeons, who
have had opportunities for observation; but I have to remark, that
no dislocation of that description has occurred at St. Thomas's
or Guy's Hospital, within the last thirty years, or in my private
practice ; and although I would not deny the possibility of its
occurrence, yet I am disposed to believe that some mistake has
arisen upon this subject.
DISLOCATION UPWARDS, OR ON THE DORSUM ILII.
This dislocation is the most frequent of those which happen to ^dislocation
^ 1 l on the dor-
the hip-joint ; and the following are the signs of its existence : sumiin.
The dislocated limb, is from one inch and a half, to two inches symptoms.
and a half shorter than the other, as is well seen by comparing
the malleoli interni, when the foot is bent at right angles with
the leg. The toe rests upon the tarsus of the other foot ; the
knee and foot are turned inwards, and the knee is a little
advanced upon the other. When the attempt is made to separate
the leg from the other, it cannot be accomplished, for the limb
is fimly fixed in its new situation, so far as regards its motion
outwards ; but the thigh can be slightly bent across the other.
If the bone be not concealed by extravasation of blood, the head
of the thigh-bone can be perceived during rotation of the knee
inwards, moving upon the dorsum ilii ; and the trochanter major
advances towards its anterior and superior spinous process, so as
p
34 PARTICULAR DISLOCATIONS.
to be felt much nearer to it than usual. The trochanter is less
prominent than on the opposite side, for the neck of the hone and
the trochanter rest in the line of the surface of the dorsum ilii ;
and upon a comparison of the two hips, the roundness of the
dislocated side will be found to have disappeared. A surgeon,
then, called to a severe and recent injury of the hip-joint, looks
for a difference in length, change of position inwards, diminution
of motion, and decreased projection of the trochanter.
Distinction Thc accidciit with which the dislocation upwards is liable to be
from frac- ■% -i ' i c f i i f t i ' ^ i • ^ '
tuie of the confounded, is the fracture or the neck of the thiffh-bone within
neck of the "
femur. ^jjg capsular ligament. Yet the marks of distinction are, in gene-
ral, sufficiently strong to prevent an error in a person commonly
attentive. In a fracture of the neck of the thigh-bone, the knee
and foot are generally turned outwards ; the trochanter is drawn
upAvards and backwards, resting upon the dorsum ilii ; the thigh
can be readily bent towards the abdomen, although with some
pain ; but, above all, the limb, which is shortened according to the
duration of the accident, from one to two inches, by the contraction
of the muscles, can be made of the length of the other by a
slight extension : and when the extension is abandoned, the leg is
again shortened. If, when drawn down, the limb is rotated, a
crepitus can often be felt, which ceases to be perceived, when
rotation is performed under a shortened state of the limb. Frac-
ture of the neck of the thigh-bone, within the capsular ligament,
rarely occurs but in advanced age, and it is the effect of the most
trifling accident, owing to the interstitial absorption which this
part of the bone undergoes at advanced periods of life. Fractures
externally to the capsular ligament, occur at any age, and they
PARTICULAR DISLOCATIONS. 35
are easily disting-iiished by the crepitus which attends them, if the
limb be rotated and the trochanter compressed with the hand.
The position is the same as in fractures within the lig-ament.
Fractures of the neck of the thigh-bone are very frequent
accidents when compared with dislocations. (See the plate of the
positions of the limb in dislocations. J
Diseases of the hip-ioint can scarcely ever be confounded with Diseases of
^ " •' the hip-joint
dislocations from violence, but by those who are ignorant of
anatomy, and who are very superficial observers. The gradual
progress of the symptoms, the pain in the knee, with the apparent
elongation at first, and real shortening afterwards ; the capacity
for motion, yet the pain given under extremes of rotation, as well
as of flexion and extension, are marks of difference which would
strike the most careless observer. The consequences of a disease
of this kind, when it has existed a great length of time, are,
ulceration of the ligaments, acetabulum, and head of the bone,
which allow of such a change of situation of parts, as sometimes
to give to the limb the position of dislocation ; but the history of
the case at once informs the medical attendant of the nature of
the disease.
This dislocation may be caused by a fall when the knee and cause.
foot of the patient are turned inwards, or by a blow whilst the
limb is in that position ; and the head of the bone is thus dis-
placed upwards, and turned backwards.
In the reduction of this dislocation, the following plan is to
be adopted : — take from the patient from twelve to twenty ounces
of blood, or even more, if he be a very strong man ; and then
place him in a warm bath, at the heat of 100°, and gradually
F 2
36 PARTICULAR DISLOCATIONS.
increase it to 110', until he feels faint. During the time he is in
the warm bath, give him a grain of tartarized antimony every
ten minutes until he feels some nausea ; then remove him from
the bath and put him in blankets : he is then to be placed between
two strong posts about ten feet asunder, in which two staples
are fixed; or rings may be screwed into the floor, and the patient
be laid upon it. My usual method is, to place him on a table
, covered with a thick blanket, upon his back ; then a strong girt
is passed between his pudendum and thigh, and this is fixed to
one of the staples. (See plate.) A wetted linen roller is tightly
applied just above the knee, and upon this a leather strap is
buckled, having two straps with rings at right angles with the
circular part. The knee is to be slightly bent, but not quite
at a right angle, and brought across the other thigh a little
above the knee of that limb. The pullies are fixed in the other
staple, and in the straps above the knee. The patient being thus
adjusted, the surgeon slightly draws the string of the pulley,
and when he sees that every part of the bandage is upon the
stretch, and the patient begins to complain, he waits a little
to give the muscles time to fatigue ; he then draws again, and
when the patient suffers much, again rests, until the muscles
yield. Thus he gradually proceeds until he finds the head of the
bone approach the acetabulum. When it reaches the lip of that
cavity, he gives the pulley to an assistant, and desires him to
preserve the same state of extension, and the surgeon then rotates
the knee and foot gently, but not with a violence to excite
opposition in the muscles, and in this act the bone slips into its
place. In general, it does not return with a snap into its socket
PARTICULAR DISLOCATIONS. 37
when the pullies are employed, because the muscles are so much
relaxed, that they have not sufficient tone remaining' to permit
them to act with violence, and the surgeon ascertaining- the
reduction only by loosening the bandages, and comparing the
length of the limbs.
It often happens that the bandages get loose before the exten-
sion is completed, an accident which should be guarded against
as much as possible, by having them well secured at first ; but if
they require to be renewed, this should be expeditiously per-
formed, to prevent the muscles having time to recover their tone.
It is sometimes necessary to lift the bone, by placing the arm
under it, near the joint, when there is difficulty in bringing it
over the lip of the acetabulum ; or a napkin may be passed under
it as near the head of the bone as possible, and by its means
an assistant may raise it. After the reduction, in consequence
of the relaxed state of the muscles, great care is required in
removing the patient to his bed.
I have seen a reduction of the bone effected, even where the
extension was not made in the best possible direction ; for when
the muscles have not had time to settle, they will allow the bone
to be restored into its socket, even when extension is made in a
direction not the most favourable for its reduction. I cannot by
any means subscribe to the method adopted by the late Mr. Hey,
although no person feels greater respect for his talents, more
highly appreciates his acquirements, or is more disposed to pursue
the study of the profession in the mode which he so successfully
adopted. The direction which he gave to a limb, in the case
which he has represented of this accident, was one little calculated
38 PARTICULAR DISLOCATIONS.
to succeed, where the means were not used immediately after the
injury had been sustained. But I state this with great deference,
because I am not sure, that in all respects, I understand the
description of the method which he adopted ; nor do I think that I
should be able, from that description, to be certain that I was
pursuing" the means by which he succeeded.
I may here observe, and I trust without ostentation, that the
plans which I have recommended, are the result of considerable
experience ; that they have been successful in a great number of
cases ; and that they have very rarely failed, under the most dis-
advantageous circumstances : they may require a little variation,
from some slight difference in the position, but this will only be
an exception to a general rule, and will very rarely occur.
The following cases will serve as illustrations of the history
and treatment of dislocations on the dorsum ilii : the first of them
points out in a striking manner the evils that ensue when dis-
location of the hip-joint remains unreduced, and the advantages
arising from the use of pullies in eifecting its reduction. It shews
also that such dislocation may happen in a strong healthy man,
even after he has attained the age of sixty.
Cases of Dislocation on the Dorsum Ilii.
CASE I.
James Ivory, aged sixty-two, of Pottensend, Herts, on the yth
of Feb. 1810, was working in a clay-pit about twenty-five feet
below the surface of the earth, when a large quantity of clay fell
PARTICULAR DISLOCATIONS. 39
in upon him, while he was in the act of stooping with his left knee
bent rather behind the other ; and he was in this position buried
under the earth. Being soon removed from his perilous situation,
and carried home, a surgeon was sent for, who, discovering the
accident to be a dislocation, directly employed some men to extend
the limb, whilst he attempted to push the head of the bone into
the acetabulum ; but all his efforts were unavailing, as, unfor-
tunately for the patient, pullies were not employed. The appear-
ances of the limb at present, when nine years have elapsed since
the accident, are these : the limb is three inches and a half shorter
than the other, and the patient is obliged to wear a shoe having
an additional sole of three inches on that side, which lessens,
though it does not prevent, his halt in walking. When he stands,
the foot of the injured limb rests upon the other ; the toes are
turned inwards, and the knee, which is advanced upon the other,
is also inverted, and rests upon the side of the patella of the sound
limb, and upon the vastus internus muscle ; it is also bent, and
cannot be completely extended. The thigh, from the unemployed
state of several of the muscles, is very much wasted ; but the
semi-tendinosus, semi-membranosus, and biceps, owing to the
shortened state of the limb, form a considerable rounded projec-
tion on the back part of the thigh. The trochanter major is
seven eighths of an inch nearer to the spine of the ilium of the
injured side than of the other. On viewing him behind, the tro-
chanter major is seen projecting on the injured side much farther
than on the other ; the situation of the head of the bone on the
dorsum ilii, is easily perceived ; and when the limb is rotated
40 PARTICULAR DISLOCATIONS.
inwards, it is still more obvious. The spinous processes of the ilia
are of an equal height. In the sitting posture, the foot is turned
very much inwards, and the knee is placed behind the other,
whilst the toe only reaches the ground. If fatigued, he experi-
ences pain in the opposite hip, and in the thigh of the injured
limb. This unfortunate man has an arduous task to gain his
bread by his labour, as he cannot stoop but with the greatest
difficulty, and is therefore obliged to seek those employments
which least require that position. When he attempts to take any
thing from the ground, he bends the knee of the injured limb
at right angles with the thigh, and throws it far back. He can
now stand for a few seconds upon the dislocated limb, but it was
twelve months before he could do so. When in bed, it is painful
to him to lie on the injured side. His hip, without any apparent
cause, is much weaker at some times than at others. When
sitting down to evacuate his faeces, he is obliged to support himself
by resting the injured knee against the tendo Achillis of the other
leg, placing his right hand on the ground. He now walks with
two sticks ; at first he employed crutches, and these he used for
twelve months, after which, he was enabled to trust to one crutch
and a stick, until his limb acquired greater strength. In getting
over a stile, he raises the injured limb two steps, and then turns
over the sound limb ; but this he cannot accomplish when the
steps are far apart; and he is frequently obliged either to turn
back, or to take a circuitous route. When lying with his face
downwards, the dislocated hip projects very much. He sometimes
falls in walking, and would very frequently do so, but that he
PARTICULAR DISLOCATIONS. 41
takes extreme care,' as the least check to his motion throws him
down. The knee is bent, and the shortening of the limb partly
depends upon that circumstance.
The following' cases illustrate the method of reduction detailed
in the preceding pages, and shew in strong colours, the advantages
to be derived from constitutional treatment, and the use of pullies.
CASE II.
John Forster, aged twenty-two years, was admitted into the
Chester Infirmary, July 10th, 1818, with a dislocation of the thigh
on the dorsum ilii, occasioned by a cart passing over the pelvis.
Upon examination, I found the leg shorter than the other, and the
knee and foot turned inwards. The patient being firmly confined
upon a table, I extended the limb by pullies, for fifty minutes
without success, and he was returned to bed for three hours ;
after which he was put in the warm bath for twenty minutes,
and the extension Avas repeated for fifteen minutes unsuccessfully ;
I therefore took twenty-four ounces of blood from him, and gave
him forty drops of tinct. opii. Continuing the extension, but not
succeeding in producing faintness, I gave small doses of a solution
of tartrate of antimony, which, in a quarter of an hour, produced
nausea ; in ten minutes afterwards, 1 succeeded in reducing the
limb, and in less than a fortnight he left the Infirmary quite well.
Unfortunately, he began to work hard immediately, and brought
on an inflammation of the hip, of which he has not recovered.
Chester. S. R. Bennett.
42 PARTICULAR DISLOCATIONS.
CASE III.
Sir,
I beg leave to forward to you the particulars of the follow-
ing case : —
John Lee, aged thirty-three, of a strong and robust constitu-
tion, in passing over a foot-bridge, October 9th, 1819, fell from a
height of about four feet on a large stone, and dislocated his left
hip. I did not see him until the 4th of December, when I found
the limb full three inches shorter than the other, the knee turned
in, the foot directed over the opposite tarsus, and the trochanter
major brought nearer the spinous process of the ilium. On laying
the man on his face, the head of the femur and trochanter could
be distinctly seen on the dorsum ilii, so as to leave not the slight-
est doubt of the nature of the injury. With the assistance of a
neighbouring practitioner, I immediately set about to reduce it ; a
girt was applied between the legs, and a bandage over the knee,
to fix the pullies, &c., in the usual manner. I then made the
extension downwards and inwards, crossing the opposite thigh two
thirds downwards ; and immediately when the extension was com-
menced, I gave him a solution of two grains of tartar emetic, which
was repeated five times every ten minutes, but it produced very
slight nausea. I shortly after bled him to sixty ounces without
syncope ; and after keeping up the extension gradually for about
two hours, with all the force one man could employ with the
pullies, we found the limb as long as the opposite; we then endea-
voured to lift the head of the bone over the acetabulum, bv means
of a towel under the thigh and over one of our heads, at the same
PARTICULAR DISLOCATIONS. 43
time rotating the limb outwards with all the force we were able to
exert ; the foot at length became somewhat turned out, and the
head of the bone to be less distinctly felt, and in about half an
hour we heard a grating of the head of the bone, when the man
instantly exclaimed it was replaced;* and, upon examination, find-
ing the foot turned out, the limb of its natural length, and no
appearance of the head of the bone on the dorsum ilii, we con-
cluded it must be within the acetabulum, and desisted from any
further violence, put the man to bed, and tied his legs together ;
his foot iiiimediately became sensible, which it had not been before
since the accident, and he altogether felt easier. A large blister
was applied over the trochanter, and he slept well in the night,
and complained of pain only in the perineum and just above the
knee, where the bandages had been applied ; there was no subse-
quent fever, nor any unpleasant symptom whatever.
In a few days the man could bear slight flexion and extension
without pain, and in a week some degree of rotation ; the limb
became gradually stronger, and the power of motion so increased,
that on the twelfth day he could by himself bring the thigh at
right angles with the body. He was now taken out of bed, and
bandages were applied round the thigh and pelvis, and he could
stand perfectly upright, so as to walk with his heel on the ground
with the assistance of crutches: and, from exercise, he grew so
rapidly stronger, that on the twenty-second day he left off one
crutch, and on the twenty-fifth the other. In a month he was able
* 111 dislocations which have remained long unreduced, the bone does not usually snap into its
socket at its reduction. — A. C.
G 2
44 PARTICULAR DISLOCATIONS.
to walk without a stick; and in five weeks, having particular
business, he walked nearly twenty miles, perfectly upright, and
without the least limping.
I am, my dear Sir,
Collumpton, Devon. Your's very truly,
Jan. 27, 1820. S. Nott.
The following case forms a striking contrast to the preceding,
and to some of those hereafter related.
CASE IV.
I was desired to visit a man aged twenty-eight years, who, by
the overturning of a coach, had dislocated his left hip more than
five weeks before ; and who had been declared not to have a dis-
location, although the case was extremely well marked. His
leg was full two inches shorter than the other ; his knee and foot
were turned inwards ; and the inner side of the foot rested upon
the metatarsal bones of the other leg. The thigh was slightly
bent toAvards the abdomen, and the knee was advanced over the
other thigh. The head of the thigh-bone could be distinctly felt
upon the dorsum of the ilium ; and when the two hips were com-
pared, the natural roundness of the dislocated side had disap-
peared. I used only mechanical means in my attempts at
reduction, and although I employed the puUies, and varied the
direction of repeated extensions, I could not succeed in replacing
the bone, and this person returned to the country with the dislo-
cation unreduced.
PARTICULAR DISLOCATIONS. 45
The following' case was communicated by Mr. Norwood,
surg-eon, Hertford.
CASE V.
William Newman, a strong muscular man, nearly thirty years
of age, was admitted into Guy's Hospital, on Wednesday, Decem-
ber 4th, 1812, under the care of Mr. Astley Cooper, for a dislo-
cation of the hip-joint. In springing from the shafts of a waggon,
on Thursday, November 7th, his foot slipped, and his hip was
driven against the wheel with considerable force. He immediately
fell, and being found unable to walk, was carried to Kingston
Workhouse, which was near the place where the accident hap-
pened. On the evening of that day, he was examined by a
medical man, but the nature of the accident was not ascertained.
He remained at Kingston until the SOth of November, knd was
then removed to Guildford, his place of residence, and from thence,
on the 4th of December, to Guy's Hospital. On examination,
the head of the thigh-bone was found resting* on the dorsum ilii ;
the trochanter was thrown forward towards the anterior superior
spinous process of the ilium. The knee and foot were turned
inwards, and the limb shortened one inch and a half; the great
toe rested upon the metatarsal bone of the other foot, and there
was but little motion in the limb.
On Saturday, the 7th of December, being thirty days after the
accident, an extension was made to reduce the limb ; and previ-
ously to the application of the bandage, he was bled to twenty-four
ounces from his arm ; in about ten minutes after this he was put
into a warm bath, where he remained until he became faint, which
46 PARTICULAR DISLOCATIONS.
happened in fifteen minutes ; he then had a grain of tartarized
antimony given him, which was repeated in sixteen minutes, as
the first dose did not produce nausea. The most distressing-
nausea was now quickly produced, but he did not vomit ; and
while under the influence of this debilitating cause, he was carried
into the operating theatre in a state of great exhaustion. Being
placed on a table on his left side, the bandage was applied in the
usual manner to fix the pelvis, and the pullies were fastened to a
strap around the knee ; the thigh was drawn obliquely across the
other, not quite two thirds of its length downwards, and the
extension was continued for ten minutes, when the bone slipped
into its socket. The man was discharged from the hospital in
three weeks from the period of his admission, making rapid pro-
gress towards a recovery of the perfect use and strength of the
limb.
For the history of the following case, I am obliged to Mr.
Thomas, apothecary to St. Luke's Hospital, who attended this
case while acting as dresser at St. Thomas's Hospital.
CASE VI.
William Chapman, aged fifty years, was admitted into St.
Thomas's Hospital, on Thursday, September 10th, 1812, with a
dislocation of the left hip upon the dorsum ilii, which was occa-
sioned by the mast of a ship falling upon the part and throwing
him down, on the Wednesday sia? weeJcs prior to his admission into
the hospital. It was reduced on Friday, the llth of September,
in the following manner. The patient was bled by opening a
PARTICULAR DISLOCATIONS. 47
vein in each arm, and thirty-four ounces of blood were taken
away. He was then put into a warm bath, and a grain of tarta-
rized antimony given to him, which was repeated every ten
minutes ; this, with the previous means, produced fainting and
nausea.
The patient was then placed on a table on his right side, and a
girt was carried between his thighs and over his pelvis, so as
completely to confine it; a wetted roller was applied above the
knee, and upon it a leathern belt, with rings for the puUies. The
extension was then made in a direction causing the dislocated
thigh to cross the other below its middle, and in half an hour the
reduction was accomplished.
The three following cases shew that we are not to despair of
success, even after a considerable time from the accident has
elapsed.
CASE VII.
Mr. Mayo has mentioned the case of William Honey, who
came into the hospital in August, 1812 : the dislocation had taken
place seven weeks before, and was reduced the day after his
admission ; he was discharged, cured, on the 18th of November.
This was a dislocation on the dorsum ilii.
CASE VIII.
Mr. Tripe, surgeon at Plymouth, has sent to the Medico-Chirur-
gical Society, an account of a case of dislocation of the thigh-bone
on the dorsum ilii, which had happened seven weeks and one day
48 PARTICULAR DISLOCATIONS.
prior to his making" an extension, in which he was so fortunate as
to succeed in restoring' the bone to its natural situation.
The following instances prove, indeed, that the dislocation
on the dorsum ilii may he reduced without pullies ; but they shew,
at the same time, how desirable the pullies would have been,
especially in the two first instances.
CASE IX.
William Piper, aged twenty-five years, sustained an injury from
the wheel of a cart, laden with hay, which passed between his
legs and over the upper part of his right thigh. IMr. Holt, sur-
geon at Tottenham, was sent for nearly a month after the accident
had happened ; he found him in great pain, attended with fever,
and with much local inflammation and tension. He bled him
largely, purged him freely, and applied leeches. The leg was
shorter than the other, and the head of the bone was seated upon
the dorsum ilii ; the knee and foot were turned inwards.
As I visited Tottenham frequently at that time, Mr. Holt asked
me to accompany him to see the man, and we agreed to the
propriety of making a trial at reduction. Mr. Holt and myself,
assisted by five strong men, exerted our best endeavours for that
purpose. Repeatedly fatigued, we were several times obliged to
pause and then renew our attempts. At length, exhausted, we
were about to abandon any further trial, but agreed to make one
last effort; when, at fifty-two minutes after the commencement of
the attempt, the bone slipped into its socket.
PARTICULAR DISLOCATIONS. 49
CASE X.
I also, in a case which I attended with Mr. Dyson, in Fore
Street, succeeded in reducing the limb without the pullies ; but
the violence used was so great, and the extension so unequal (our
fatigue being nearly as severe as that of the patient), that I am
confident no person who had used pullies in dislocation of the hip,
would have recourse to any other mode, excepting in the disloca-
tion into the foramen ovale.
CASE XL
Mary Bailey, aged seven years, was admitted into Guy's Hospi-
tal, June 16th, 1819, under the care of Mr. Astley Cooper, for a
dislocation of the os femoris upwards on the dorsum ilii. This
accident was occasioned by the child swinging on the shaft of
a cart, which, being insecurely propped, suddenly gave way, and
she fell to the ground upon her side. The nature of the accident
was exceedingly evident ; the limb on the dislocated side was at
least two inches shorter than the other ; the toe rested on the
tarsus of the opposite foot, and was turned inwards ; the knee was
also inverted and rested on the other. The child was admitted into
the hospital at half-past five in the afternoon, the accident having
happened a little more than half an hour before. Where so little
resistance was expected the pullies appeared unnecessary, and
towels were substituted, one being applied above the knee, and
the other between the pudendum and thigh ; then, bending the
knee, and bringing the thigh across the other just above the knee,
gradual extension was made, and in about four minutes the head
H
50 . PARTICULAR DISLOCATIONS.
of the bone suddenly snapt into its socket. On the seventh day the
child was walking in her ward, and suffered little inconvenience.
To Mr. Daniel, one of Mr. Lucas's dressers, I am obliged for
the foregoing particulars ; he having reduced the limb in the
presence of many of the students.
CASE XII.
In this case the extension was made at the ancle, and it is
consequently worthy of attention;
My dear Sir,
William Sharpe, an athletic young man, in wrestling,
received a fall ; his antagonist falling with and upon him, their
legs were so entangled that he cannot say how he came to the
ground. He complained of great pain in the hip, and was inca-
pable of rising. About twenty minutes after the accident, I found
him lying on his belly in the field where it had occurred, and the
left limb in a trifling state of abduction, shortened, and the knee
and foot turned inwards, the prominency of the trochanter gone,
and the head of the bone obscurely felt on the dorsum ilii. He
was conveyed home, and in order to reduce the dislocation, for
such I considered it, I placed the man on his right side diagonally
across a four-post bedstead. The centre of a large sheet, rolled
up, was passed in front and behind the body, and fastened to the
upper bed-post, as low as possible. The centre of a napkin, rolled
in like manner, was then applied upon the dorsum ilii, between its
crista and the dislocated bone ; and each extremity being brought
PARTICULAR DISLOCATIONS. 51
under the sheet, forwards and backwards, was reflected over it
and tied in the centre, by which means I hoped to keep the pelvis
secure ; the counter-extending* force was applied above the ancle
(it appearing' to me to interfere less with the muscles upon the
thigh), first, by rolling round a wetted towel, and then placing
upon this the end of a long or jack-towel : three men were now
directed to pull gradually and steadily ; and when I perceived that
the head of the femur was brought down to the edge of the
acetabulum, I raised it a little with my clasped hands, placed
under the upper part of the thigh, and immediately the head of
the bone entered the cotyloide cavity with a smart snapping noise.
The man had considerable pain about the hip and knee for some
time, but is now quite well.
I am, dear Sir,
Nottingham, Your's truly,
August 8th, 1819. Henry Oldnow.
CASE XIII.
Dudley/, January 19^A, 1824.
Dear Sir,
A youth, about sixteen or eighteen years of age, while at
his work in a pit, was buried under a fall of coals ; and besides
being severely injured in several other parts of his body, had one
hip dislocated on to the dorsum of the ilium, and the same thigh
broken about the middle of the bone. As the reduction of the
hip was, of course, impracticable, the thigh was bound up in the
usual manner, and treated without any reference to the dislocation
of the joint, with a hope that when the thigh-bone was re-united,
H 2
52 PARTICULAR DISLOCATIONS.
tlie hip might possibly be reduced. At the end of five weeks, the
bone appearing tolerably firm, I had a very careful but unremitting
extension of the limb made by means of pulUes, and, in less than
half an hour, had the satisfaction of feeling the head of the bone
re-enter the socket. It is very probable that the reduction would
have been accomplished in less time, had I dared to allow a more
powerful extension of the limb, but I very much feared lest a
separation of the newly united bone should be produced by it.
The patient became so upright as to shew scarcely any signs of
lameness afterwards.
I have met with several instances of these accidents conjoined
with another injury, which at first sight presented a complication
sufficiently embarrassing, but without being, in reality, productive
of much additional difficulty. I allude to cases in which, with
dislocation of one hip, there has been a fracture of the bone of the
opposite thigh. In such circumstances I have fixed some splints
temporarily, but very firmly, upon the broken limb, and then,
turning the patient on that side, have proceeded to the reduction
of the dislocated hip in the usual way. After this has been
accomplished, I have taken the splints from the broken limb, and
bound it up again in the customary manner; and every case which
I have seen has done well, without any additional inconvenience.
I once witnessed a case, which I mention rather for its singu-
larity than for any practical inference which it furnishes. — A man
had received (I forget how) a severe hurt on one of his hips.
When laid on a bed for examination, the thigh-bone was found
not to be broken, and the limbs were exactly of the same length ;
PARTICULAR DISLOCAtlONS. 53
but the foot of the injured side turned somewhat inwards, and any
attempt to move the hip-joint was extremely painful. On a more
careful examination of the parts about the hip, it was plain that
the thigh-bone was dislocated, and that its head was on the dorsum
of the ilium, and yet the limb seemed not at all shortened. A
brief enquiry, however, led to an explanation of this apparent
anomaly. It appeared that the opposite thigh-bone had been
formerly broken, and had united in such a way as to leave the
limb several inches shorter than it had originally been ; and the
dislocation of the other thigh upwards, had now brought that to a
corresponding length. It is scarcely needful to add, that the
reduction of the dislocation restored the patient to his former
lameness, and to the deformity produced by limbs of unequal
length.
With the greatest respect,
I remain, dear Sir,
Your most obedient Servant,
John Badley.
To Sir Astley Cooper.
CASE XIV.
Dislocation of the Thigh upon the Dorsum Ilii, with
Fracture of the Thigh-Bone.
Abraham Harman, aged thirteen years, a patient under Mr.
Forster, in Guy's Hospital, gave the following account of his
accident :
54 PARTICULAR DISLOCATIONS.
About four months since, he drove his master's horses to a chalk-
pit ; he went down into the pit to pack the chalk, and to break it
into small pieces, and whilst he was thus occupied, the side of the
pit gave way, and a large piece of chalk striking him violently on
the hip, knocked him down. Being immediately taken to a
neighbouring public-house, a surgeon was sent for. The thigh
was discovered to be fractured near its middle, but very consider-
able contusions prevented the dislocation from being at first
discovered. Fomentation and other means of reducing the swell-
ing at the hip being employed, it was ascertained that the thigh
was also dislocated, and some attempts were made to reduce it ;
but the fracture would not then bear the extension, and the boy
was sent to the hospital. No attempts have been made to reduce
the bone.
This case presented unusual difficulties ; and the probability is,
that dislocation thus complicated with fracture, will, generally,
not admit of reduction ; as an extension cannot be made, until
three or four months have elapsed from the accident, and then
only with strong splints upon the thigh, to prevent the risk of
disuniting the fracture.
CASE XV.
Marlborough, Feb, 12, 1823.
Sir,
Permit me to send you the following case of dislocation of
the thigh-bone on the dorsum of the ilium.
George Davies, aged thirty-five, on the first of the present
PARTICULAR DISLOCATIONS. 55
month, in descending a flight of steps at a mill in this neighbour-
hood, with a sack of wheat on his back, missed a step or two, and
in endeavouring to regain his footing, the whole weight of the
load fell upon him, and the violence of the shock bore him down
several steps lower, where he lay totally incapable of further
motion till assistance was procured.
He was then conveyed to the adjoining village. On examina-
tion, the limb was found considerably shorter than its fellow, the
foot turned inwards, and resting upon the tarsus of the other leg.
The head of the bone was distinctly felt, lodged among the glutei
muscles. All the other symptoms were unequivocal. In about
three hours after the occurrence of the accident, due preparation
having been made, thirty ounces of blood were taken from the
arm, the pullies were adjusted according to your directions, and
gradual extension being made, the head of the bone was even-
tually brought on a line with the acetabulum ; a towel was now
passed under the thigh, by which means the bone was elevated,
and suddenly, with an audible snap, it slipped into its proper
cavity. The man is going on well, but as he is still suff'ering
from the effect of the contusion, he has not been allowed to make
much use of his limb.
I am, Sir,
Your's respectfully,
T. Maurice.
P. S. The reduction was accomplished in about ten minutes.
"v
56 PARTICULAR DISLOCATIONS.
DISLOCATION DOWNWARDS, OR INTO THE
FORAMEN OVALE.
Anatomy.
accident.
The foramen ovale is formed by the junction of two bones, the
ischium and the pubes ; it is situated below the acetabulum, and is
somewhat nearer the axis of the body. It is filled by a lig-ament
which proceeds from the edges of the foramen, and has an opening
in its upper and anterior part, to permit the passage of the obtu-
rator blood-vessels, and the obturator nerve. It is covered on
its external and internal surface by the obturator externus, and
obturator internus muscles.
Mode of This dislocation happens when the thighs are widely separated
from each other. The ligamentum teres and the lower part of
the capsular ligament are torn through, and the head of the bone
becomes situated in the posterior and inner part of the thigh,
upon the obturator externus muscle.
It has been erroneously supposed, that the ligamentum teres
is not torn through in this dislocation ; because in the dead body,
when the capsular ligament is divided, the head of the bone can
be drawn over the lower edge of the acetabulum without tearing
the ligamentum teres. But the dislocation in the foramen ovale
happens whilst the thighs are widely separated, during which act
the ligamentum teres is upon the stretch ; and when the head of
the bone is thrown from the acetabulum, this ligament is torn
through before it entirely quits the cavity.
The limb is in this case two inches longer than the other. The
head of the bone can be felt by pressure of the hand, upon the
Symptoms.
PARTICULAR DISLOCATIONS. 57
inner and upper part of the thigh towards the perineum, but only
in very thin persons. The trochanter major is less prominent
than on the opposite side. The body is bent forwards, owing
to the tension of the psoas and iliacus internus muscles. The
knee is considerably advanced if the body be erect ; it is widely
separated from the other, and cannot be brought, without great
difficulty, near the axis of the body to touch the other knee,
owing to the extension of the glutei and pyriformis muscles. The
foot, though widely separated from the other, is, generally, neither
turned outwards nor inwards, although I have seen it varying a
little in this respect in diiferent instances ; but the position of the
foot does not in this case mark the accident. The bent position
of the body, the separated knees, and the increased length of the
limb, are the diagnostic symptoms. ^ The position of the head of
the bone is below, and a little anterior to, the axis of the ace-
tabulum ; and a hollow is perceived below Poupart's ligament.
We have an excellent preparation of this accident in the col- Dissection.
lection at St. Thomas's Hospital, which I dissected many years
ago. The head of the thigh-bone was found resting in the
foramen ovale, but the obturator externus muscle was completely
absorbed, as well as the ligament naturally occupying the foramen,
now entirely filled by bone. Around the foramen ovale, bony
matter was deposited so as to form a deep cup, in which the head
of the thigh-bone was inclosed, but in such a manner as to allow
of considerable motion ; and the cup thus formed, surrounded the
neck of the thigh-bone without touching it, and so inclosed its
head, that it could not be removed from its new socket without
breaking its edges. The inner side of this new cup was extremely
I
58 PARTICULAR DISLOCATIONS.
smooth, not having the least ossific projection at any part to
impede the motion of the head of the bone ; which was only-
restrained by the muscles from extensive movements. The original
acetabulum was half filled by bone, so that it could not have
received the ball of the thigh-bone if an attempt had been made to
return it into its natural situation. The head of the thigh-bone
was very little altered ; its articular cartilage still remained ; the
ligamentum teres was entirely broken, and the capsular ligament
partially torn through ; the pectinalis muscle and adductor brevis
had been lacerated, but were united by tendon ; the psoas muscle
and iliacus internus, the glutei and pyriformis, were all upon the
stretch. Nothing can be more curious, or, to the surgeon and
physiologist, more beautiful, than the changes produced by this
neglected accident, which exemplify the resources of nature in
producing restoration.
The reduction of this dislocation is in general very easily effected.
If the accident has happened recently, it is requisite to place the
patient upon his back, to separate the thighs as widely as possible,
and to place a girt between the pudendum and the upper part of
the luxated thigh, fixing it to a staple in the wall. The surgeon
then puts his hand upon the ancle of the dislocated side, and draws
it over the sound leg, or, if the thigh be very large, behind the
sound limb, and the head of the bone slips into its socket. Thus
I saw a dislocation reduced, which had happened very recently,
and which was subjected to an extension in St Thomas's Hospital,
almost immediately after the patient's admission. In a similar
case, the thigh might be fixed by a bed-post received between the
pudendum and the upper part of the limb, and the leg be carried
Reduction.
PARTICULAR DISLOCATIONS. 59
inwards across the other. But in general it is required to fix the
pelvis by a girt passed around it, and crossed under that which
passes around the thigh, to which pullies are to be attached,
otherwise the pelvis will move in the same direction with the head
of the bone. (See plate.)
In those cases in which the dislocation has existed for three or
four weeks, it is best to place the patient upon his sound side ; to
fix the pelvis by one bandage, and to carry under the dislocated
thigh another bandage, to which the pullies are to be affixed
perpendicularly; then to draw the thigh upwards, whilst the
surgeon presses down the knee and foot, to prevent the lower part
of the limb being drawn with the thigh-bone. Thus the limb is
used as a lever of very considerable power. Great care must be
taken not to advance the leg in any considerable degree, otherwise
the head of the thigh-bone will be forced behind the acetabulum
into the ischiatic notch, from whence it cannot be afterwards
reduced.
Dislocation of the Right Thigh into the Foramen Ovale.
CASE I.
A gentleman was thrown from his horse on the 4th of January,
1818, by the animal suddenly starting to the right side; and whilst
he endeavoured to keep his seat by the pressure of the right thigh
against the saddle, he was thrown, and from the fall received a
severe contusion upon his head, which produced alarming symp-
toms. On the following day it was observed that the right thigh
I 2
60 PARTICULAR DISLOCATIONS.
was useless, and that the knee was raised and could not be brought
into a straight line with the other, having- at the same time a
direction outwards, which required it to be tied to the other
knee : the symptoms of injury to the head precluded, at this time,
the attempt at reduction. In fourteen days he w'as so far recovered
that he was able to rise from his bed, and in a month he began to
walk with crutches.
On November 1st, 1818, I first saw him ; and the appearances
of the injured limb were then as follow: — the thigh was longer
than the other by the length of the patella; the knee was ad-
vanced; and when he was in the recumbent posture, the injured
leg could not be drawn down to the same length with the other.
The upper part of the thigh-bone was thrown backwards, so as to
render the hollow of the groin on the injured side deeper than that
on the other. The toes were rather everted, but when the body
was erect, were capable of resting on the ground, though the heel
was not. The head of the bone could not be felt, and the
trochanter was much less prominent than usual. When the upper
part of the thigh-bone was pressed against the new acetabulum,
and moved, there was a sensation of friction between two cartila-
ginous surfaces, which, although not easily described, is readily
distinguished from the crepitus occasioned by a fractured bone.
In a sitting posture the injured leg was two inches longer than the
other ; and to that degree the knee was projected beyond the
sound one. In progression the knee was bent; and the body being
thrown forwards the patient rested chiefly upon his toe, and halted
exceedingly in walking. The sartorious and gracilis muscles
were very much put upon the stretch. At first he suflTered much
PARTICULAR DISLOCATIONS. 61
from pain in the dislocated hip and thigh, but is now free from
pain, unless when he attempts to stand on that limb only. His
toe, at first, was with difficulty brought to the ground, but he is
now improved in walking ; for when he first made trial, with the ,
assistance of a crutch and stick, he could not exceed half a mile,
but he is now capable to walk two miles. In flexion his thigh
admits of considerable motion, but he cannot extend it further •
than to bring the ham to the plane of the other patella. The knees
cannot be brought together, but he advances one before the other
in the attempt. He can sit without pain, but the jolting of a
carriage hurts him exceedingly ; and the attempt to sit on horse-
back produces excessive suffering. He cannot straighten his leg
when his body is erect, nor can he stoop to tie his shoe on the
injured side. Pain is produced by resting on that hip in bed. No
attempt was made to reduce the limb ; the injury to the head
might have rendered it dangerous in the commencement, and at
the time Avhen I saw him there was no chance of success.
Sir,
Inclosed is the case of dislocation which you requested me
to forward to you, and I am sorry it has not been in my power
to put you in possession of it before, for reasons which I stated
when I saw you last.
I am. Sir,
LeadenJiall Street, Your obliged Servant,
February 18^^, 1820. J. S. Daniell.
62 ' PARTICULAR DISLOCATIONS.
Dislocation of the Right Femur Downwards, or into the
Foramen Ovale.
CASE II.
Mr. Thomas Clarke, a farmer, about fifty years of age, was
driving home in his cart from market, when the horse took fright
and ran away with him. The following is the account he gives
of the manner in which the accident happened : — in his endeavour
to stop the horse, he fell over the front of the cart on his face,
and the knee struck against some part of it in the act of falling,
by which means the thighs were separated ; the wheel, he also
states, passed over his hip.*
My friend, Mr. Potter, of Ongar, in Essex, whose ability as a
surgeon in that neighbourhood is justly appreciated, was con-
sulted in this case, between two and three weeks after the accident
had happened ; and, as I was visiting him at the time, I had the
pleasure of accompanying him.
The nature of the accident was extremely evident ; the limb
was fully three inches longer than the other, the body bent for-
wards, the knees separated, and the foot rather inclined outwards ;
these were the leading diagnostic marks. Mr. Potter, having
clearly ascertained the position of the dislocated limb, I accom-
panied him the following morning, in order to assist in the
reduction ; and the following were the means employed.
Our first object was to produce relaxation ; and finding the
Query. — Was this, or the extended state of the limbs, the cause of the dislocation ?
PARTICULAR DISLOCATIONS. 63
patient was sufficiently strong to bear the plan usually recom-
mended in cases of dislocation, where much resistance is ex-
pected, we drew away some blood from the arm ; this, however,
was not sufficient for our purpose, and a solution of tartar
emetic, which we had brought with us, was administered. The
patient was laid upon his side, close to the edge of the bed
(that being the most convenient place), a girt was passed round
the pelvis, and carried through the frame of the bedstead, which
completely prevented the possibility of the body moving whilst
extension was going on ; a second girt was applied between
the thighs, fixed to the one above, to which the puUies were
attached. Whilst extension was making, Mr. Potter took hold
of the limb at the knee, and drew it rather upwards, and towards
the sound thigh, occasionally rotating the limb. When the
extension had been continued about ten minutes, the nausea
produced by the tartar emetic was so excessive, that the patient
begged of us to desist until the morrow, observing, he felt so
bad that he was fearful of falling off the bed : this exclamation,
it hardly need be said, was a stimulus to our proceeding ; and in
five minutes after, the limb was suddenly heard to snap into its
original cavity. The patient was put to bed, a roller being
applied round the pelvis, and at the end of five days, he felt so
well that he left his room ; and at the expiration of a short time,
suffered no other inconvenience than stiffness in the joint.
J. S. Daniell.
Mr. Daniell's knowledge of his profession, and his zeal in the
pursuit of it, which I have had frequent opportunities of observing,
will ensure his success whenever he embarks in practice.
A. C.
64 PARTICULAR DISLOCATIONS.
Mischief Although a dislocation into the foramen ovale may be occasion-
from im-
properex- ally rcduced by attempts made in a very inappropriate direction,
yet an instance has occurred which shews the mischief that may
arise from an error in this respect.
casg I once saw the following case : — a boy, sixteen years old, had
a dislocation of the thigh into the foramen ovale : he was placed
upon his sound side, and an extension of the superior part of the
thigh was made perpendicularly ; the surgeon then pressed down
the knee, but the thigh being at that moment advanced, the
head of the bone was thrown backwards, and passed into the
ischiatic notch ; from which situation it could not be reduced.
I am indebted to Mr. Key, for the particulars of the annexed
case, which was admitted into Guy's Hospital, under Mr. Forster.
Dislocation of the Thigh into the Foramen Ovale.
CASE in.
Stephen Holmes, aged forty-one, while working in a gravel pit,
at Camberwell, was suddenly overwhelmed by a large mass of
gravel, and remained buried under it, till dug out by his com-
panions. When the gravel was removed, he was found in a
sitting posture with his legs widely separated, and unable to
approximate them. In this position he was brought to Guy's,
about seven o'clock in the evening, an hour after the accident
had happened, and was placed under the care of Mr. Carey,
dresser to Mr. Forster.
PARTICULAR DISLOCATIONS. Q^
Being undressed and placed in bed in the recumbent posture,
he was seen lying with his left thigh bent upon the pelvis, his
knee consequently elevated, and the whole limb fixed at a con-
siderable distance from the other. On carrying the eye to the
upper part of the thigh near the hip-joint, a considerable change
in form was manifest ; the projection of the trochanter was
entirely lost, and in its place a deep hollow was perceptible ; and
at the inner part of the thigh, near the pubes, a distinct projection
appeared, having the form of the head of the bone covered bv the
adductor muscles. From these general appearances, we regarded
the accident as a dislocation of the femur into the foramen ovale
of the pelvis, and proceeded to make a more minute examination
of the limb, to ascertain the precise nature of the injurv.
The man was desired to rise from his bed and sit on the edge
of it, which he did without inconvenience or pain ; in this position
his left knee projected at least two inches and a half beyond
the sound limb ; this apparent elongation of the leg, arose prin-
cipally from the oblique bearing of the pelvis, the real elongation
being afterwards ascertained to be not more than an inch and a
quarter. In the erect posture, which he maintained with some
difficulty, his body was bent forward in consequence of the pro-
jection of the pelvis over the thigh ; the knee was bent, and the
toe, which was slightly inverted, rested on the ground ; the whole
limb was advanced before the sound one, and remained in a state
of abduction. He was then laid upon a firm table on his back,
and the capability of motion in the limb was carefully noted.
His knee was first bent toward his breast without any difficulty,
and to as full an extent as the opposite limb ; the power of
K
66 PARTICULAR DISLOCATIONS.
abduction was also complete, and the attempt was unattended
with pain ; but extension and adduction of the thigh were the
motions most impeded. When the limb was made to approximate
to the sound one, which could not be done without producing- pain
and numbness on the inner side of the thigh, the patellae remained
eleven inches distant from each other; and as soon as the hand
was withdrawn from the ancle, the leg flew outward with a spring,
from the reaction of the two small glutcei. The limb could not
be carried backward, but remained permanently bent at the hip-
joint ; and when any attempt was made to fix it, the patient com-
plained of great pain in the direction of the psoas and iliacus
muscles. The depression observed at the site of the trochanter
was such as to render it difficult to feel that process ; while on
the inner side of the thigh, a distinct projection was formed by the
head of the bone, which could be felt under the adductors. These
latter muscles were rendered very tense by the projecting bone.
The nates appeared to preserve their usual form.
Reduction. — Having never had an opportunity of witnessing
this kind of dislocation since my attendance at the hospitals,
during the last eight years, I wished to see how far the method
of reduction which you have laid down was applicable in the pre-
sent case. Your " Treatise on Dislocations and Fractures" being
in the hands of one of the students, we referred to the plate, and
proceeded to apply the pullies and bandage in the manner there
delineated. The apparatus being once carefully and securely
adjusted, required no alteration, as it neither slipped from its situ-
ation, nor occasioned any inconvenience to the patient. Extension
was then made by drawing the displaced limb across its fellow.
PARTICULAR DISLOCATIONS. Q^
while the piilHes drew the head of the bone outwards ; but in
doing this, we ran some risque of throwing the head of the femur
into the ischiatic notch ; for the thigh being large and fleshy at
the back part, was, when drawn across the other, necessarily
carried somewhat forward, and thus tilted the head of the bone
backward : had any alteration taken place in the situation of the
head of the femur during this extension, it would have been
carried under the acetabulum into the ischiatic notch, it was
therefore thought adviseable to carry the leg behind the sound
one ; and as soon as this was done, the head returned, with an
audible crash, into the acetabulum. The whole extension occupied
fifteen minutes.
This species of dislocation of the femur, is by far the most easy
of reduction of any that has come under my observation ; and it
may be presumed, that had the leg at first been carried behind
instead of before the other, the replacement of the limb might
have been effected immediately. Where the limb is large it is
impossible to carry it in a right line across its fellow; and,
perhaps, in order to avoid the danger to which I have alluded,
and which I have often heard you point out in your lectures, it
would be as well to adopt the line of extension which in this
instance answered so well.
October 15, 1822. — This patient could stand by the side of his
bed without support in a week after the accident.
W. A. Key.
K 2
68
PARTICULAR DISLOCATIONS.
structure.
DISLOCATION BACKWARDS, OR INTO THE
ISCHIATIC NOTCH.
Anatomical TliG spacc which is called the ischiatic notch is bounded above
and anteriorly by the ilium, posteriorly by the sacrum, and inferi-
orly by the sacro-sciatic ligament. It is formed for the purpose
of giving passage to the pyriformis muscle and to the sciatic
nerve, as well as to the three arteries, the glutseal, the ischiatic,
and the internal pudendal. In the natural position of the pelvis,
it is situated posteriorly to the acetabulum and a little above its
level. When the head of the bone is thrown into this space, it is
placed backwards and upwards, with respect to the acetabulum ;
therefore, although I call this the dislocation backwards, it is to
be remembered that it is a dislocation backwards and a little
upwards.
In this dislocation the head of the thigh-bone is placed on the
pyriformis muscle, between the edge of the bone which forms the
upper part of the ischiatic notch, and the sacro-sciatic ligaments,
behind the acetabulum, and a little above the level of the middle
of that cavity.
This dislocation is the most difficult both to detect and to
reduce : to detect, because the length of the limb differs but little,
and its position, in regard to the knee and foot, is not so much
changed as in the dislocations upwards : to reduce, because the
head of the bone is placed deep behind the acetabulum, and it
therefore requires to be lifted over the edge of that cavity, as well
as to be drawn towards its socket.
Nature of
the accident.
Detection
difficult.
PARTICULAR DISLOCATIONS. 69
The signs of this dislocation are, that the limb is from half an signs,
inch to one inch shorter than the other, but generally not more
than half an inch ; that the trochanter major is behind its usual
place, but is still remaining nearly at right angles with the ilium,
with a slight inclination towards the acetabulum. The head of
the bone is so buried in the ischiatic notch that it cannot be
distinctly felt, except in thin persons, and then only by rolling the
thigh-bone forwards as far as the comparatively fixed state of the
limb will allow. The knee and foot are turned inwards, but less
than in the dislocation upwards ; and the toe rests against the ball
of the great toe of the other foot. When the patient is standing,
the toe touches the ground, but the heel does not quite reach it.
The knee is not so much advanced as in the dislocation upwards,
but is still brought a little more forwards than the other, and is
slightly bent. The limb is so fixed that flexion and rotation are
in a great degree prevented.
We have a good specimen of this accident in the collection at Dissection.
St. Thomas's Hospital, which I met with accidentally, in a subject
brought for dissection. The original acetabulum is entirely filled
with a ligamentous substance, so that the head of the bone could
not have been returned into it. The capsular ligament is torn
from its connection with the acetabulum, at its anterior and
posterior junction, but not at its superior and inferior. The
ligamentum teres is broken, and an inch of it still adheres to the
head of the bone. The head of the bone rests behind the aceta-
bulum on the pyriformis muscle, at the edge of the notch, above
the sacro-sciatic ligaments. The muscle on Avhich it rests is
diminished, but there has been no attempt made to form a new
70 PARTICULAR DISLOCATIONS.
bony socket for the head of the os femoris. Around the head of
the thigh-bone a new capsular hgament is formed ; it does not
adhere to the articulatory cartilage of the ball of the bone which
it surrounds, but could, when opened, be turned back to the neck
of the thigh-bone, so as to leave its head completely exposed.
Within this new capsular ligament, which is formed of the
surrounding cellular membrane, the broken ligamentum teres is
found. (See plate.) The trochanter major is placed rather
behind the acetabulum, but inclined towards it relatively to the
head of the bone.
In this specimen, from the appearance of the parts, the
dislocation must have existed many years ; the adhesions were too
strong to have admitted of any reduction, and if reduced, the bone
could not have remained in its original socket.
Cause. This spccics of dislocation is produced by the application of
force, when the body is bent forward upon the thigh, or when the
thigh is bent at right angles with the abdomen ; when, if the
knee be pressed iuAvard, the head of the bone is thrown behind
the acetabulum.
The reduction of the dislocation in the ischiatic notch, is, in
general, extremely difficult, and is best effected in the following
manner : the patient should be laid on a table upon his side, and
a girt should be placed between the pudendum and the inner part
of the thigh, to fix the pelvis. Then a wetted roller is to be
applied around the knee, and the leathern strap over it. A napkin
is to be carried under the upper part of the thigh. The thigh-
bone is then to be brought across the middle of the other thigh,
measuring from the pubes to the knee, and the extension is to be
PARTICULAR DISLOCATIONS. 71
made with the pullies. Whilst this is in progress, an assistant
pulls the napkin at the upper part of the thigh with one hand,
rests the other upon the brim of the pelvis, and thus lifts the bone,
as it is drawn towards the acetabulum, over its lip. For the
napkin I have seen a round towel very conveniently substituted,
and this was carried under the upper part of the thigh, and over
the shoulders of an assistant, who then rested both his hands on
the pelvis, as he raised his body, and lifted the thigh. (See plate.)
Although the preceding is the method in which this dislo-
cation is most easily reduced, yet I have seen a different mode
practised; and I shall mention it here, as it shews how the muscles
opposing the pullies, will draw the head of the bone to its socket,
when it is lifted from the cavity into which it has fallen.
CASE L
A man, aged twenty-five, was admitted into Guy's Hospital,
under the care of Mr. Lucas ; upon examination, the thigh was
found dislocated backwards ; the limb scarcely differed in length
from the other, not being more than half an inch shorter; the
groin appeared depressed ; the trochanter was resting a little
behind the acetabulum, but inclined upon it ; the knee and foot
were turned inwards, and the head of the bone could, in this case,
be felt behind the acetabulum. An extension was made by pullies
in a right line with the body ; at the same time, the trochanter
major was thrust forward with the hand, and the bone returned
in about two minutes into its socket with a violent snap.
I have already mentioned, that I have seen no instance of a
72 PARTICULAR DISLOCATIONS.
dislocation dotvnwards and backwards ; and when I state, that
I have been an attentive observer of the practice of our hospitals
for thirty years, was also for many years in the habit of daily
seeing the poor of London at my house early in the morning", and
have had a considerable share of private practice, I may be allowed
to observe, that if such a case does ever occur, it must be ex-
tremely rare. I cannot help thinking, also, that some anatomical
error must have given rise to this opinion, as, in the dislocation
downwards and backwards, the head of the bone is described as
being received still into the ischiatic notch ; but this notch is, in
the natural position of the pelvis, above the level of the line drawn
through the middle of the acetabulum ; and hence it is, that the
leg becomes, not shorter, but longer, when the bone is dislocated
into the ischiatic notch.
Dislocation of the Right Thigh into the Ischiatic Notch.
The following case I received from Mr. Rogers, a very intel-
ligent surgeon, at Manningtree.
CASE ir.
Dear Sir,
William Dawson, aged thirty-four, on the 15th of August,
1818, while spending his harvest-home with several of his
companions, became quarrelsome with one of them, who threw
him down and trod upon him. Upon extricating himself, and
endeavouring to rise, he found some serious injury to his right
PARTICULAR DISLOCATIONS. 73
thigh, rendering him incapable of standing ; in this state he was
dragged by his associates for many hundred yards into a stable,
where he lay till the next morning. I then saw him lying upon a
mattress, with the hip and thigh, on the right side, prodigiously
swollen and painful ; and I was particularly struck with the
appearances of the knee and foot on the same side, which were
very much turned inwards, but the limb was scarcely shortened.
T ordered him to be carefully conveyed home upon a shutter,
supported by six men, a distance of about half a mile. From the
immense swelling and general enlargement of the whole of the
thigh, and of the soft parts around the pelvis, it was impossible
to ascertain exactly the state of the injury ; but it was fully
impressed upon my mind, that there was some unusual dislocation
of the head of the thigh-bone. He was accordingly ordered
immediately to lose blood, both by general and topical means,
and emollient poultices were applied to the whole of the swollen
parts ; brisk purgatives were also administered, succeeded by
saline medicines, and a quiet position was enjoined for eleven
days, by which time the swelling began somewhat to subside.
Still the precise nature of the injury was not satisfactorily evident ;
but it was thought by Mr. Nunn, of Colchester, and Mr. Travis,
of East Bergholt, who had kindly come over to witness it, that
there was a luxation. The only difficulty we had in reconciling
this notion to ourselves was, the belief in our minds that no author
had adduced an instance of this accident, without an alteration in
the length of the limb, except it might be Mr. Astley Cooper,
in his new publication, which neither of us had yet seen. We
accordingly had recourse to a minute examination of the skeleton ;
L
J4: PARTICULAR DISLOCATIONS.
when we immediately fancied we could account for the absence of
the usual marked signs of displacement of the head of the bone,
excepting the inversion of the knee and foot, in this kind of luxa-
tion ; for we noticed, that if the head of the bone be luxated
sideways into the ischiatic notch, it will produce scarcely any
difference in the length of the limb. Trusting that a little further
delay might not be attended with any material disadvantage, but
give a chance for the entire subsidence of all the inflammation and
swelling, we proposed meeting again as soon as we conveniently
could, by which time we might consult Mr. Cooper's book. We
accordingly met on Sunday, the 30th of August, which was fifteen
days after the accident ; and from the complete removal of all
swelling, the whole of the femoral bone was satisfactorily traced
to its rounded head, which was lodged in the ischiatic notch.
Upon referring to the "Essays," which we had now before us,
we had the case delineated and described ; and as it was exhibited
in a plate, we had only to imitate, in order to accomplish the
reduction of the bone. In the presence of two or three other
medical gentlemen, who had now joined us, we commenced the
operation ; and as it would be unnecessary to state every par-
ticular, considering the manner in which the position of the
patient, and the fixing of the pullies and towels, are demonstrated
by that publication, suffice it for me to remark, that, after ten or
twelve minutes of gradual extension, the reduction of the bone
was most readily and admirably accomplished.
Preparatory to commencing the operation, we took thirty
ounces of blood from the arm ad deliquium, and afterwards,
while fixing the pullies, &c., we gave four grains of tartarized
PARTICULAR DISLOCATIONS. 75
antimony, at intervals, to produce nausea. Immediately after the
operation, we gave one grain of opium, applied sedative lotions
to the parts, and proceeding carefully for about a fortnight, the
patient was enabled to move upon crutches, and was shortly after
sent home perfectly well.
I am your's,
Manningtree, John Rogers.
August 15thf 1818.
The relation of the foregoing case, from the kind manner in
which Mr. Rogers has expressed himself, may savour a little of
vanity ; but I shall readily suffer this imputation ; as it will ever
be ray greatest gratification to find that my humble endeavours
may, in the slightest degree, have conduced to the advantage of
my professional brethren, or to the benefit of those who may be
placed under their care.
The dislocation in the ischiatic notch has been, as far as I incorrect
know, in every author who has written on the subject, incorrectly by authors.
described ; for it has been stated, that the limb was lengthened
in this accident, and I need scarcely mention the mistakes in prac-
tice to which so erroneous an opinion has given rise ; one instance,
however, of such an error I must here give. A gentleman wrote
to me from the country in these words : — " I have a case under
my care of injury to the hip, and I should suppose it a dislocation
into the ischiatic notch, but that the limb is shorter, instead of
being longer, as authors state it to be." Into this error those
authors must have fallen from having examined a pelvis separated
L 2
'^6 PARTICULAR DISLOCATIONS.
from the skeleton, and observed that the ischiatic notch was
below the level of the acetabulunci when the pelvis was horizontal,
although it is above the acetabulum in the natural oblique position
of the pelvis, at least, as regards the horizontal axis of the two
cavities. It is to be remembered, that there is no such accident
as a dislocation of the hip downwards and backwards.
CASE III.
John Cockburn, a strong muscular man, aged thirty-three, was
admitted into Guy's Hospital on the 31st of July, 1819. While
carrying a bag of sand, at Hastings, on the 24th of June, he
slipped, and dislocated the left hip-joint ; and the following is the
account he gives of the accident: — the foot on the affected side
was plunged suddenly into a hollow in the road, which turned his
knee inwards at the same time that his body fell with violence
forwards. On the day on which the accident happened, two
attempts were made to reduce the dislocation by puHies, but
without success ; and, on the 27th of June, a third, but equally
unsuccessful, trial was made, although continued for nearly an
hour. He was directed to Guy's Hospital by IMr. Stewart, surgeon
at Hastings.
It was found upon examination, after he had been admitted,
that the thigh was dislocated backwards into the ischiatic notch,
the limb was a little shortened, the knee and foot were turned
inwards, and the toe rested on the ball of the great toe of the
other foot ; the head of the bone could not be felt ; the trochanter
major was opposite the acetabulum, the rim of which could be
distinctly perceived. When the body was fixed, the thigh could
PARTICULAR DISLOCATIONS. 77
be bent so as nearly to touch the abdomen. The patient was
carried into the operating theatre soon after his admission ;
and when two pounds of blood had been taken from him, and he
had been nauseated by two grains of tartarized antimony, gradu-
ally administered, extension was made with the pullies in a right
line with the body, and the upper part of the thigh was raised
while the knee was depressed ; the extension was continued at
least for an hour and a half, during which time he took two grains
more of tartarized antimony, by which he was thoroughly nau-
seated ; the attempts, however, at reduction, did not succeed.
On the 3rd of August, the tenth day from the accident, Mr.
Astley Cooper succeeded in reducing it in the following manner:
— he ordered so much blood to be taken from the arm as to
produce a feeling of faintness. A table was placed in the centre,
between two staples, upon which the patient was laid on his right
side ; a girt was passed between the scrotum and the thigh, and
carried over the pelvis to the staple behind him ; and thus the
pelvis was, as far as possible, fixed; a wetted roller was carried
around the lower part of the thigh, just above the knee, and a
leathern strap buckled on it, to which, and to a staple before the
limb, the pullies were fixed. The body was bent at right angles
with the thigh, which crossed the upper part of the other thigh :
then the extension with the pullies was begun, and gradually
increased until it became as great as the patient could bear. An
assistant was then directed to get upon the table, and to carry a
strong band under the upper part of the thigh, by which he lifted
it from the pelvis, so as to give an opportunity for the head of the
bone to be turned into its socket. Mr. South, who held the leg.
78 PARTICULAR DISLOCATIONS.
was directed to rotate the limb inwards, and the bone, in thirteen
minutes, was heard to snap suddenly and violently into its socket.
James Chapman,
Dresser at Guys Hospital.
To whom I am indebted for the foreg'oing statement.
I believe that, in this case, I should not have succeeded in
reducing the limb, but from attention to two circumstances : first,
I observed that the pelvis advanced within the strap which was
employed to confine it, so that the thigh did not remain at right
angles ; and I was obliged to bend the body forwards to preserve
the right angle during extension ; and, secondly, the extension
might have been continued for any length of time, yet the limb
would never have been reduced, but by the rotation of the head of
the thigh-bone towards the acetabulum.
Mr. Wickham, jun. of Winchester, has had the kindness to
inform me of a case of this dislocation which had been admitted
into the Winchester Hospital, under the care of Mr. Mayo, one
of the surgeons of that Institution, whose permission I have to
state the following circumstances.
CASE IV.
Winchester, August 10, 1819.
John Norgott, aged forty, was brought to the hospital on the
27th of December, 18175 from the neighbourhood of Alton, with
PARTICULAR DISLOCATIONS. 79
an injury of the hip ; twelve days had elapsed since the accident,
without his being aware of the nature of the injury. He reported
that his horse had fallen with him and on him, so that one leg was
under the horse, whilst his body was in a half-bent position,
leaning against a bank. He was of middle stature, but very
muscular ; the leg was very inconsiderably shorter than the other,
and but little advancing over it ; in fact, the immobility of the
limb was the chief criterion of the dislocation ; for the head of the
bone was thrown into the ischiatic notch. The mode of reduction
was simple : Mr. Mayo had the limb extended by the pullies, so as
to bring the head of the bone to the edge of the acetabulum, over
which it was then tilted by a towel, fastened round the patient's
thigh and the neck of an assistant. The man remained three or
four weeks before he was allowed to leave the house ; but on the
4th of February he was discharged, cured.
The following case was communicated by Mr. Worts, dresser
to Mr, Chandler, surgeon to St. Thomas's Hospital.
CASE V.
James Hodgson, a sailor, aged thirty-eight years, a strong-
muscular man, was admitted into St. Thomas's Hospital, on
Tuesday, the 18th of February, for an injury which he had
received in his left hip ; his foot was raised from the ground upon
a chest of fruit, when another fell upon his thigh, striking the
knee inwards ; he fell, and being taken up extremely hurt, he
was directly brought to the hospital. Upon examination, I
conceived that it was a dislocation of the hip-joint, and that the
80 PARTICULAR DISLOCATIONS.
head of the bone was thrown into the ischiatic notch. Some
difference of opinion, however, arose upon the subject ; and as
considerable tension existed, which prevented the head of the
bone from bein^ distinctly felt, I ordered an evaporating lotion,
and left the case for future investigation. Upon further consider-
ation, my opinion was strengthened concerning the nature of the
injury, as it was clearly pointed out by the diminished length of
the leg, which was three quarters of an inch shorter than the
other, and by the inversion of the foot ; although there was in this
case more power of flexion in the limb than might have been
expected, but no rotation outwards. Mr. Chandler saw the case
on Saturday the 12th, and, on account of the tension, he ordered
some leeches to be applied to the part, and the lotion to be
continued. Mr. Cline saAV it this afternoon, and thought it a
dislocation in the ischiatic notch.
Monday morning, the 14th. The swelling had greatly subsided,
and I thought I could now feel the head of the bone on rotation
of the limb. Mr. Chandler saw the case again this morning, and
expressed a wish for Mr. A. Cooper to see it. Mr. Cooper, at my
request, very kindly saw it in the evening, and immediately
declared it to be a dislocation into the ischiatic notch ; and upon
his rotating the thigh, I could much more distinctly than before
feel the head of the bone in the ischiatic notch. Mr. Cooper
recommended me to take away blood, which I did the next
morning, to the amount of sixteen ounces ; this considerably
relieved the pain the man had previously suffered, and the tension
continued to abate till the Saturday morning following, when
Mr. Chandler again saw him, and he thought it had sufficiently
PARTICULAR DISLOCATIONS. 81
subsided to justify the attempt at reduction. I accordingly made
preparations in the following manner : — at about half-past two
o'clock, I took sixteen ounces of blood from the patient, which
produced no sensible effect ; at ten minutes past three, I took
about twenty-seven ounces more, and while the blood was flowing,
gave him a grain of emetic tartar ; this I repeated till he had
taken five grains at intervals of a few minutes ; and as he was
becoming faint, he was taken into the theatre. I applied the
bandages and puUies to the pelvis and to the knee, bringing the
thigh over the other; we kept up the extension about ten or
twelve minutes before we used the strap to raise the head of the
bone, and until I thought it had made some progress towards
the acetabulum. We then continued the extension, gradually
increasing it, at the same time endeavouring to raise the head of
the bone and turning the knee outwards, for about fifteen minutes.
I had now lost the head of the bone, but still, as it had not made
the usual noise in its reduction, I thought that it would be wrong
to remove the puUies, as the action of the muscles, if the bone had
not been reduced, would have again drawn it up, in which opinion
Mr. Martin, who assisted me, concurred. The man was now very
faint, the extension was therefore continued for about twenty-five
minutes longer, when the strap at the knee getting rather loose,
we removed the pullies, upon which it was found that the thigh
could now be moved in any direction, and that its position was
perfectly natural. The bone was replaced, but at what time it
had gained its situation no one could judge, neither could the
man describe any feeling that could have indicated it ; he was
carried to bed in a very faint state.
M
82 PARTICULAR DISLOCATIONS.
He had no sickness during' or after the extension. I gave him
a grain and a half of opium at night, which procured rest.
Sunday morning. — He had some pain remaining, but it was
greatly abated, and the thigh could be moved in any direction.
W. Worts,
Feb. 22, 1820. Dresser to St. Thomas's.
Mr. Worts naturally expresses surprise that the bone was
reduced without its entering the acetabulum with the usual noise;
but when the muscles have been some time contracted, and when
the patient is rendered faint by bleeding, and by the nausea of
tartarized antimony, they do not act with the same violence as in
the first few hours after the accident.
Cause.
DISLOCATION ON THE PUBES.
This dislocation is more easy of detection than any other of the
thigh. It happens when a person, while walking, puts his foot
into some unexpected hollow in the ground ; and his body at the
moment being bent backwards, the head of the bone is thrown
forwards upon the os pubis. A gentleman, who had met with this
dislocation in his own person, informed me that it happened whilst
he was walking across a paved yard in the dark : he did not know
that one of the stones had been taken up, and his foot suddenly
sunk into the hollow, and he fell backwards. When his limb was
PARTICULAR DISLOCATIONS. 83
examined, the head of the thigh-bone was found upon the os
pubis.
In this species of dislocation the limb is an inch shorter than symptoms.
the other, the knee and the foot are turned outwards, and cannot
be rotated inwards, but there is a slight flexion forwards and out-
wards ; and in a dislocation which had been long* unreduced, the
motion of the knee backwards and forwards was full twelve inches;
but the striking criterion of this dislocation is, that the head of the
thigh-bone may be distinctly felt upon the pubes, above the level
of Poupart's ligament, on the outer side of the femoral artery and
vein ; and it feels as a hard ball there, which is readily perceived
to move by bending the thigh-bone.
Although this dislocation is apparently easy of detection, I have Not detected
known three instances in which it was overlooked, until it was
too late for reduction ; of one, we have now a preparation at St.
Thomas's Hospital; another occurred to a gentleman from the
country, in whom it was not discovered until some weeks after
the accident, who then submitted to an extension which did not
succeed, and came to London to ask my opinion, when I advised
him against a further attempt ; and, indeed, he himself was
disinclined to any other trial. The third was a patient in Guy's
Hospital, who was admitted for an ulcerated leg, and was found
to have a dislocation upon the pubes, which had happened some
years before. It really must be great carelessness Avhich leads
to this error, as the case is so strikingly marked.
I dissected one of these dislocations, and we have it preserved Dissected.
in our anatomical collection. It shews changes of parts nearly
equal to those of the dislocation into the foramen ovale. The
M 2
84 PARTICULAR DISLOCATIONS.
original acetabulum is partially filled by bone, and in part occupied
by the trochanter major, and both are much altered in their form.
The capsular ligament is extensively lacerated, and the ligamen-
tum teres broken. The head of the thigh-bone had torn up Pou-
part's ligament, so as to be admitted between it and the pubes.
The head and neck of the bone were thrown into a position under
the iliacus internus and psoas muscles ; the tendons of which, in
passing to their insertions over the neck of the bone, were elevated
by it, and put on the stretch. The crural nerve passed on the
fore part of the neck of the bone upon the iliacus internus and
psoas muscles. The head and neck of the thigh-bone were
flattened, and much changed in their form. Upon the pubes a
new acetabulum is formed for the neck of the thigh-bone, for
the head of the bone is above the level of the pubes. The new
acetabulum extends upon each side of the neck of the bone, so
as to lock it laterally upon the pubes. (See plate.) Poupart's
ligament confines it on the fore part ; on the inner side of the
neck of the bone passed the artery and vein, so that the head of
the bone was seated between the crural sheath and the anterior
and inferior spinous process of the ilium.
Distinguish- This accidcut might, by an inattentive observer, be mistaken
ed from /• /• p . /.
fracture. for a fracturc of the neck of the thigh-bone ; but the head of
the bone felt upon the pubes will decide its nature.
In the reduction of this dislocation, the patient is to be
placed on his side on a table; a girt is to be carried between the
pudendum and inner part of the thigh, and fixed in a staple
a little before the line of the body. The pullies are fixed above
the knee, as in the dislocation upwards, and then the extension
Reduction.
PARTICULAR DISLOCATIONS. 85
is to be made in a line behind the axis of the body, the thigh-
bone being drawn backwards, (See plate.) After this extension
has been for some time continued, a napkin is to be placed under
the upper part of the thigh, and an assistant, pressing with one
hand on the pelvis, lifts the head of the bone, by means of the
napkin, over the pubes and edge of the acetabulum.
The following case, which occurred in Guy's Hospital at the
time when my friend, Mr. now Dr. Gaitskill, was dresser to
Mr. Forster, will best exemplify the mode of reduction. He
was a dresser in the years 1803 and 1804.
Bath, August 13, 1817.
Dear Sir,
The report of the case of dislocated thigh, which I have
sent you, contains every material circumstance within my recol-
lection ; it will afford me much pleasure if you can extract any
thing from it useful or conducive to your purpose.
I remain your's most sincerely,
Joseph A. Gaitskill.
CASE.
A. B. with a dislocation of the os femoris upon the pubes,
was admitted into Guy's Hospital, under Mr. Forster, during
the time I was one of his dressers.
The length of the limb was somewhat diminished ; the foot
and knee were turned outwards ; but the circumstance which
86 PARTICULAR DISLOCATIONS.
more clearly evinced the nature of the accident was, that the
head of the thigh-bone could be distinctly perceived under the
integuments near the groin, where its shape could be ascertained,
as well as its motion felt, when the thig'h was moved. The
accident had happened from a slip or fall he had sustained about
three hours before.
With respect to the reduction; as the man was brought into
the hospital in the evening, when Mr. Forster was absent, I
considered it to be my duty to attempt to replace the bone im-
mediately. I therefore ordered the patient to be carried into the
operating theatre ; whilst this was doing, I invited my three
brother dressers into the surgery, informed them of the accident,
and, to avoid confusion, requested each to take some particular
part in the process of reduction. The patient was placed on his
sound side on a table, the pullies applied to the thigh in the usual
manner, and extension began in a straight line, with the design
of raising the head of the bone into its socket, but without suc-
cess. Reflecting then a moment on the mechanism of the bones,
and their new relative situation, I changed the line of extension
to a little backwards and downwards, and passing a towel over
my own shoulders, and mider the superior part of the man's thigh,
raised it by extending my body.
The leg being kept bent, as from the beginning of the opera-
tion, nearly to a right angle with the thigh, I requested one of
the dressers to take hold of the ancle, and raise it, keeping the
knee at the same time depressed, by which means the thigh was
turned over inwards, and in a very short time, the head of the
bone snapped into its acetabulum.
J. A. G.
PARTICULAR DISLOCATIONS. 87
The following case was admitted into St. Thomas's Hospital,
under the care of Mr. Tyrrell.
CASE.
Guildhall, February/ 7th, 1823.
My dear Sir,
I take this opportunity of giving you the particulars of the
case of dislocation on the pubes, which you wished for.
Charles Pugh, aged fifty-five, a cooper, about the middle size,
on the evening of the 23rd of January, during the time he was
making water at the corner of a street, was struck on the back
part of the right hip by the wheel of a cart ; and the blow
knocked him down. He was taken up by some persons passing,
who, finding that he was not able to walk, took him to St.
Thomas's Hospital. The accident happened about nine o'clock
in the evening, and I was sent for between twelve and one o'clock,
when I found a dislocation of the right femur on the pubis, the
particulars of which were as follows : —
The head of the bone could be distinctly felt below Poupart's
ligament, immediately on the outer side of the femoral vessels.
The foot and knee were turned outwards, with very little altera-
tion in the length of the limb. The thigh was not flexed towards
the abdomen, and was almost immoveable, admitting only of
partial adduction and abduction. The limb could be rotated
outwards, but not at all inwards. I immediately had the man
taken into the operating theatre, and speedily succeeded in
reducing the dislocation by the following means : — the patient
88 PARTICULAR DISLOCATIONS.
was placed on his left side, a broad band was passed between the
thighs, and, being tied over the crista of the ilium on the right
side, was made fast to a ring fixed in the wall. A wet roller
having been put on above the right knee, a bandage was buckled
over it, and its straps attached to the hooks of the pullies, by
which a gradual extension was made, drawing the thigh a little
backwards and downwards. When this extension had been kept
up a short time, I directed another bandage to be applied round
the upper part of the thigh, close to the perineum, by means of
which the head of the bone was raised, and in the course of a
few minutes the reduction was easily accomplished. The patient
had not been bled or taken any medicine, he suffered but little
after the reduction, and was able to walk without pain or incon-
venience five or six days afterwards. On the day following the
accident, he could move the limb freely in all directions with-
out pain, but did not attempt to walk until the period I have
mentioned.
If I have omitted any points, or if you have any wish for
further particulars, a message or a note by post, will much oblige
Your's very sincerely,
Frederick Tyrrell,
Surgeon to St. Thomas's Hospital.
From what I have had an opportunity of observing on the
subject of dislocations, I believe that the relative proportion of
PARTICULAR DISLOCATIONS. 89
cases will be in twenty as follows : twelve on the dorsum ilii ;
five in the ischiatic notch ; two in the foramen ovale ; and one
on the pubes.
The cases I have here detailed, with the dates at which they
occurred, shew the frequency with which these accidents happen.
The manner in which it escaped the observation of surgeons of
eminence of former times, can only be accounted for by the diffi-
culties which then existed in the pursuit of anatomy, and more
especially of morbid anatomy : and it is a curious circumstance,
that Mr. Sharpe, formerly surgeon of Guy's Hospital, author of a
Treatise on Surgery, and in many respects an excellent surgeon,
who had a large share of the practice of this town, did not, as I
was informed by Mr. Cline, believe that a dislocation of the thigh-
bone ever occurred.
It is really gratifying to observe the difference of knowledge
in the profession at the present period compared with that of fifty
years ago. What should we think of a surgeon in the metropolis
in the present day, with all his opportunities of seeing disease in
the large hospitals of this city, who doubted the existence of a
dislocation of the thigh, when we find that our provincial surgeons
immediately detect the nature of these injuries, and generally
succeed in their attempts to reduce them ? Let them never for-
get, however, that it is to their knowledge of anatomy, and, more
especially, of morbid anatomy, that they are indebted for this
superiority.
N
90 PARTICULAR DISLOCATIONS.
Mr. Charles H. Todd, surgeon to the Richmond Surgical Hos-
pital, and Professor of Anatomy and Surg-ery at Dublin, has lately
published "An Account of a Dissection of the Hip-Joint after
recent Luxation, with Observations on the Dislocations of the
Femur upwards and backwards ;" from which the following case
is extracted :
CASE.
In the summer of 1818, a robust young man, in attempting to
escape from his bed-room window, in the second floor of a lofty
house, fell into a flagged area ; by which accident, his cranium
was fractured, and his left thigh dislocated upwards and back-
wards.
The dislocation was reduced without difficulty ; however, an
extensive extravasation of blood having taken place on the brain,
the patient lingered in a comatose state for about twenty-four
hours, and then died. On the next day, dissection was performed,
and the following appearances were observed in the injured joint
and the parts contiguous to it :
On raising the gluteus maximus, a large cavity, filled with
. coagulated blood, was found between that muscle and the poste-
rior part of the gluteus medius : this was the situation which had
been occupied by the dislocated extremity of the femur. The
gluteus medius and minimus were uninjured. The pyriformis,
gemini, obturatores, and quadratus, were completely torn across.
Some fibres of the pectinalis were also torn. The iliacus, psoas^
and adductores were uninjured. The orbicular ligament was
entire at the superior and anterior part only, and it was irre-
gularly lacerated throughout the remainder of its extent. The
PARTICULAR DISLOCATIONS. 91
inter-articular ligament was torn out of the depression on the
head of the femur, as in Dr. Scott's case, its attachment to the
acetabulum remaining- perfect. The bones had not sustained
any injury.
The following case, which has recently appeared in one of the
Medical Journals, from JVir. Cornish, surgeon at Falmouth, I have
thought proper to subjoin, though I must observe, that there is
reason to suspect some mistake in the relation, not of the narrator
of the case, but of the man himself ; as I have carefully examined
the books of both hospitals at the period specified, and can find
no such name. It is, however, possible that the patient may be
able to explain the difficulty ; but I wish Mr. Cornish to make
further enquiries.
CASE.
In 1812, Mac Fadder, a seaman, about twenty years of age,
in coming up from Greenwich to London on the outside of one
of the stages, fell from the coach and injured his hip. He was
carried into St. Thomas's Hospital, and became Mr. Cline's patient.
His case was treated as fracture of the neck of the thigh-bone.
Having, after the lapse of some months, experienced no relief from
the means that were adopted, he was dismissed with the assur-
ance, that the limb would be useless to him as long as he lived.
The man was subsequently taken into Guy's Hospital. Sir A.
Cooper, whose patient he became, thought the head of the femur
out of the socket ; and after bleeding him, putting him into the
warm bath, and administering nauseating doses of tartrate of
N 2
92 PARTICULAR DISLOCATIONS.
antimony, attempted to reduce the dislocation. The attempt was
unsuccessful, as were also others that were afterwards made, and
he was again dismissed as an incurable cripple.
In 1813, about twelve months after the accident, the man
presented himself on crutches at the Falmouth Dispensary, when
he gave me the foregoing history of his case. On examining
him, I found the injured limb about two inches and a half shorter
than the other, entirely useless, producing great pain on bringing
it to the ground, and the knee and foot turned inwards. There
was considerable distortion about the joint ; and the head of the
bone appeared to have formed a bed for itself among the muscles
on the dorsum ilii. In short, he had every diagnostic symptom
of the dislocation upwards.
In consequence of the duration of the accident, and the failure
of the attempts at reduction under the management of Sir. A.
Cooper, I considered his case a hopeless one, and therefore did
nothing for him.
In March, 1818, I met the man carrying a heavy basket on
each arm, and walking without the slightest degree of lameness.
Although I intimately knew his person, having seen him on
crutches about the town for two or three years, I passed him,
hardly believing it within the compass of possibility, that he
could be my lame patient ; but after having walked twenty
yards or more, I ran back after him to ascertain the fact. On
satisfying myself of his identity, of which I entertained such
doubt, and on enquiring into the cause of his cure, he informed
me, that in the summer of 1817, five years after the accident,
whilst on a passage from Falmouth to Plymouth, in a little
PARTICULAR DISLOCATIONS. 93
coasting vessel, " the ship made a lurch," by which he was thrown
out of his birth. At the moment he fell, he heard a loud crack
in his hip, and from that time he put aside his crutches, and
recovered the perfect use of his limb. The man is now doing
duty, as an able seaman, on board a ship which trades from this
port to London.
The practical importance of this case is not, perhaps, equal to
the curious character of its termination. " It proves," says Mr.
Cornish, " the possibility of reducing a displaced joint, even after
the lapse of years, when every impediment to reduction may be
fairly supposed to exist (particularly the obliteration of the ace-
tabulum), and when most surgeons would judge the attempt
hopeless ; and it serves to illustrate the proposition, that * a slight
effort, when the muscles are unprepared, will succeed in reduction
of dislocation, after violent measures have failed.' "
FRACTURES of the OS INNOMINATUM.
Mistake. ^g thesG accidciits are liable to be mistaken for dislocations,
and as any extension made for them adds extremely to the
patient's sufferings, and would be liable to produce fatal conse-
quences if there existed previously a probability of recovery, I am
anxious to say a few words upon them.
Symptoms. Whcu a fracturc of the os innominatum happens through
the acetabulum, the head of the bone is drawn upwards, and
the trochanter somewhat forwards, so that the leg is shortened,
and the knee and foot are turned inwards : such a case may be
readily mistaken for dislocation into the ischiatic notch. If the
OS innominatum is disjointed from the sacrum, and the pubes
and ischium are broken, the limb is a slight degree shorter than
the other; but in this case the knee and foot are not turned
inwards, but outwards. Of the first of these accidents I have
seen two examples, of the latter only one.
FRACTURES OF THE OS INNOMINATUM. 95
These accidents are generally to be detected by a perceptible Detection.
crepitus on the motion of the thig"h, if the hand be placed upon
the crista of the ilium ; and they are attended with more motion
than occurs in dislocations.
With respect to the appearances on dissection, they will be seen
in plate seventh.
CASE.
A man was brought into St. Thomas's Hospital, in January,
1791, on whom a hogshead of sugar had fallen. Upon exami-
nation the right leg was found about two inches shorter than the
left, and the knee and foot were turned inwards ; these circum-
stances induced the surgeon under whose care he fell to think the
case a dislocation, although, as he stated, the limb appeared to
be more moveable than usually happens in such accidents, and
there was a great contusion and considerable extravasation of
blood. The surgeon used the utmost caution in making a very
slight extension, in order to bring the legs to an equal length, in
which he did not succeed ; and whilst it was performing, a crepitus
was discovered in the os innominatum. The man had a remark-
able depression of strength, and paleness of countenance, and
appeared to be sinking. In the evening he died.
Upon examination of the body the following appearances were
observed : — The posterior part of the acetabulum was broken off,
and the head of the thigh-bone had slipped from its socket ; the
tendon of the obturator internus, and the gemini, tightly embraced
the neck of the bone ; the fracture extended from the acetabulum
across the os innominatum to the pubes ; the ossa pubis were
96 FRACTURES OF THE OS INNOMINATUM.
separated at the symphysis nearly an inch asunder, and a portion
of the cartilage was torn from the right piibes, and adhered to
that on the left side ; the ilia were separated on each side, and
the puhes, ischium, and ilium broken on the left side ; the abdo-
men contained about a pint of blood, and the left kidney was
greatly bruised ; the integuments were stript off the patella and
knee on one side, so as to expose the capsular ligament.
In a second case of this kind, which was admitted into St.
Thomas's Hospital, having the appearance of the dislocation
backwards, the patient lived four days. On examination, the
fracture was found passing through the acetabulum, dividing the
bone into three parts ; and the head of the thigh-bone was deeply
sunk into the cavity of the pelvis.
The following case of fracture and dislocation of the bones of
the pelvis lately occurred in Guy's Hospital : I am obliged for
the particulars to Mr. Sandford, who attended to this patient
as dresser.
CASE.
Mary Griffiths, aged thirty years, was admitted into Guy's
Hospital at five o'clock in the afternoon of the 8th of August,
1817. Her pelvis had sustained a severe injury, from her body
being pressed by the wheel of a cart against a lamp-post.
A small quantity of blood had been taken from her arm previ-
ous to her admission ; and as she was very pale, her pulse
extremely weak, and her feeces passed involuntary, no more
blood was drawn.
FRACTURES OF THE OS INNOMINATUM. 97
Soon after her admission she was examined ; when, by placing
her on the face, with one of my hands on the back of the right
ilimn, and the other on the pubes of the same side, a distinct
motion and crepitus could be perceived. The posterior spine of
the ilium projected upwards, above its usual junction with the
sacrum, and it was thought that the ilium was dislocated from the
sacrum, with some fracture, either of the ilium, or the sacrum.
When she was turned on the back, and examined per vaginam,
the pubes were found passing more into the cavity of the pelvis
than usual. A large quantity of blood was effused from the last
rib to the upper part of the thigh, on the right side.
It was now a question whether this extravasated blood should
not be discharged by making an opening through the integu-
ments, as it appeared to be fluid ; but upon consideration, it was
thought that the vessels would still bleed, that she could not bear
the loss of blood in her weakened state, and that the blood, Avhen
coagulated, would form the best security against further effusion.
All that was done, therefore, was to roll a broad bandage round
the pelvis to fix it firmly, to give tinct. opii. gt. xxx., and to draw
off the urine from her bladder, which contained about a pint.
In the evening, the extravasation of blood was somewhat in-
creased, and she complained of a pricking sensation in the right
thigh and leg, which induced her to loosen the bandage. She
had vomited ; her feet were cold : she had severe pain, and great
thirst ; her pulse was 90, and small.
On the 9th, she complained of a sensation of one side tearing
from the other; and, upon examination of the lower extremities,
that on the right side was found shorter than the other ; there
o
98 FRACTURES OP THE OS INNOMINATUM.
was numbness also on that side. Her tongue was furred, but her
pain and thirst somewhat less ; and she had not the same cold-
ness in her feet as she had the night previous.
As her bowels had not been relieved since her admission,
aperient medicine was given to her ; and the bladder being
incapable of emptying itself, a catheter was employed. The
ecchymosis was of great extent, and it was doubtful whether it
could be absorbed. A pillow was placed against the right side to
support the pelvis, and another was put under the knee, to pre-
serve the limb in an easy position.
In the evening of this day, her pulse was 112. She complained
much of pain in the right side and groin. The catheter was
again obliged to be used, and aperient medicines to be repeated.
On the morning of the 10th, she complained of the bones of
the pelvis moving upon each other, even more than at any former
period, and that she had suffered severe pain ; the tongue was
now furred, her pulse fuller, but her bowels had been relieved,
and she had made water without assistance. At one o'clock this
day, her pulse being fuller, and 120 in a minute, with great heat
of skin, I bled her to the amount of ten ounces ; but the blood
did not exhibit any signs of inflammation, nor did the loss of
blood produce any apparent effect in relieving her symptoms.
In the evening, her pain and fever had increased ; and as she
complained of the tightness of the bandage which still surrounded
the pelvis, it was removed. The catheter was again obliged to
be employed. Some saline medicine, with opium, was directed
for her.
On the Uth, she stated that she had passed a good night. Her
FRACTURES OP THE OS INNOMINATUM. 99
pulse was 120 and softer; her tongue furred: she was directed
to continue her medicines.
A stimulating lotion was ordered her on the 12th, to produce
an absorption of the extravasated blood. Some spots appeared of
a very dark colour, where the ecchymosis had been most severe,
and the cuticle was abraded upon those parts.
On the 13th her report w^as more favourable; her bowels were
open, and her bladder did not require the assistance of the catheter.
However, she still complained of severe pain in the hip.
14th. As the excoriated parts seemed disposed to slough, a
puncture was made through the integuments, nearly opposite to
the trochanter major, and a quart of serum, mixed with the red
particles of blood, and with a substance which appeared adipose,
was discharged.
On the 15th the faeces and urine had passed into her bed, and
she requested to be removed to another; her pulse was 112.
The puncture made yesterday does not seem disposed to heal, and
a poultice was directed for it.
16th. She expressed herself relieved by her removal into
another bed; her pain is less severe; her pulse but 108. She
was now directed a diet to support her strength, and some porter
was given her ; but on the 17th, as she had been observed to be
slightly delirious the preceding night, the quantity of porter was
lessened.
On the 18th the sloughing of the part, which had been exces-
sively bruised, had considerably increased ; yet her tongue was
cleaner, and her skin of its natural heat.
o 2
100 FRACTURES OF THE OS INNOMINATUM.
On the foUowing^ day she appeared better ; had passed a good
night : she was ordered a poultice of stale beer-grounds to the
hip ; and as she strongly requested it, she was turned on her left
side, as her impression was, it would relieve the pain she felt on
the right side.
The sloughing of the superior and posterior part of the thigh
had increased upon the 20th ; and she was ordered the decoction
and tincture of bark, with saline medicine if her thirst became
urgent ; and a more nutritious diet.
On the 21st, the sloughing had increased; the tongue was
furred ; her pulse was 120. On the 22nd she was worse ; and
on the 23rd, her stomach rejected every thing : she had a strong
impression that she could not recover; she refused her medicine,
and the slough had increased. In the evening of the 24th, she
died.
Examination.
On the 25th, the body was examined. — A fracture was found
passing through the body of the pubes on the left side, and
through the ramus of the left ischium.
The right os innominatum was separated from the sacrum at
the sacro-iliac symphysis, and a part of the transverse processes
of the sacrum was broken off, and torn from the sacrum with
the ligaments. The cartilage and ligaments of the symphysis
pubis were torn, and the left sacro-iliac symj^hysis had given
way ; the ligament over it being torn, and the bones separated
sufficiently to admit of the handle of a scalpel being received
between them. (See plate.)
FRACTURES OF THE OS INNOMINATUM. 101
Blood was found extravasated in the pelvis, behind the peri-
toneum.
Jonathan Sandford.
I have known three instances of recovery from simple fracture
of the OS innominatum : two of these were fractures of the ilium,
and the nature of the accident was easily detected by the crepitus
which was perceived upon moving- the crista of the ilium ; the
third case was a fracture at the junction of the ramus of the
ischium and pubes. In the two first a circular roller was applied
upon the pelvis, and the patient was freely bled ; but in the latter
no bandage was employed. I have also known a compound frac-
ture of the OS innominatum recover; but Mr. Hulbert, surgeon, sent
me a compound fracture of the ilium, which had proved fatal.
Several cases have also occurred within my knowledge of
fracture of the pubes, near its symphysis, accompanied with
laceration of the bladder, each of which proved destructive ; but
when the bones have been broken without injury to the bladder,
the patients have recovered.* The bladder is burst or not, in this
accident, according to its state of distention or emptiness at the
moment of the accident ; for, if empty, it escapes injury.
* There Is at this time (Sept. 1823), a case in Guy's Hospital, in which the bladder is believed to
be ruptured below the reflexion of the peritoneum, and between it and the pubes, and the man appears
recovering by wearing a catheter. But in cases where the injury is above the line of reflexion of the
peritoneum, the urine escapes into the cavity of the abdomen, and excites general inflammation.
FRACTURES OF THE UPPER PART
OF THE THIGH-BONE.
Before I enter into a description of the dislocations of other
joints, it will be proper to point out the fractures incident to
the upper part of the thigh-bone, as it is essentially necessary
that these accidents should not be confounded with dislocations,
or with each other, a mistake which has but too frequently
happened. Indeed it must be confessed, that their discriminating
marks are sometimes with difficulty detected, and that the different
species of fracture are likewise frequently confounded ; for three
distinct species, very different in their nature and in their result,
have been described and classed under the indiscriminate appella-
tion of fracture of the neck of the thigh-bone. Hence has arisen
that difference of opinion, which has led to much discussion
respecting the processes which nature employs for their cure, and
which less hypothetical reasoning, and more attention to the
development of such accidents by dissection, would have been
FRACTURES OF THE UPPER PART OF THE THIGH-BONE. 103
the means of preventing. Whilst one surgeon asserts that all
attempts to cure them are unavailing, another maintains that they
admit of union like fractures of other bones ; which latter opinion
is only true as far as regards two species of these fractures.
I shall now, therefore, proceed to state the results of my obser-
vations in living persons who have been the subjects of these
accidents ; of my examination of the dead body ; and of some
experiments upon inferior animals, which illustrate this subject.
These accidents are more frequent than dislocations of the
thigh-bone ; for whilst we receive into our hospitals of Guy's
and St. Thomas's (containing about nine hundred persons), not
more upon an average than two such dislocations in a year,
our wards are seldom without an example of fracture of the
upper part of the thigh-bone.
Different Species of Fracture of the Upper Part
OF THE ThIGH-BoNE.
These are, as we have already observed, three in number.
First : That in which the fracture happens through the neck of
the bone entirely within the capsular ligament.
Secondly: A fracture external to the ligament, through the
neck of the thigh-bone at its junction with the trochanter major ;
by which the trochanter is split, and the neck of the thigh-bone
is received into its cancelli.
Thirdly : A fracture through the trochanter major, beyond its
junction with the cervix femoris.
104 FRACTURES OF THE UPPER PART
FRACTURES OF THE NECK OF THE THIGH-BONE,
WITHIN THE CAPSULAR LIGAMENT.
Appearances fhe appeavaiices which are produced by this fracture are as
follows : — the leg becomes from one to two inches shorter than
the other ; for the connection of the trochanter major with the
head of the bone, by means of the cervix, being destroyed by
the fracture, the trochanter is drawn up by the muscles as high
as the ligament will permit, and consequently rests upon the edge
Difference in ^f ^jjg acctabulum, and upon the ilium above it. The difference
length. i
in the length of the limbs is best observed by desiring the patient
to place himself in the recumbent posture on his back, when, by
comparing the malleoli, it will be generally found that one leg is
shorter than the other. The usual state of the limb is, that the
heel on the injured side rests in the hollow between the malleolus
internus and tendo Achillis of the other leg; but there is some
variety in this respect ; a fork is sometimes formed in the trochan-
ter minor, which catches the neck of the bone, and prevents
a greater ascent than half an inch (see plate). Mr. Brodie
informs me that he dissected a case in which the cervix was
obliquely broken, and in which the upper part of the bone pre-
vented the ascent of the lower. On the other hand, when the
fracture has happened for a length of time, and the patient has
borne upon the injured limb, the ligament becomes extended, and
the leg is shortened four inches ; of this Mr. Langstaff mentioned
to me an instance in a man of the name of Campbell, aged
OF THE THIGH-BONE. 105
eighty-two, in whom the heel was obliged to be elevated four
inches to make the bearing of the limbs equal. I saw the frac-
tured parts in this man, and the shoe he wore, which entirely
verified Mr. L.'s statement. The retraction is at first easily
removed by draAving down the shortened limb, when it will appear
of the same length with the other; but immediately when this
extension is abandoned, and the patient exerts himself, the mus-
cles draw it into its former position ; and this appearance may
be repeatedly produced by extending the limb. This evidence
of the nature of the accident continues until the muscles acquire
a fixed contraction, which enables them to resist an extension
which is not of a powerful kind.
Another circumstance which marks the nature of this injury is. Foot turned
. . J? ^ c 11 outward.
the eversion ot the loot and knee ; and this state depends upon
the numerous and strong external rotatory muscles of the hip-
joint, which proceed from the pelvis to be inserted into the
thigh-bone, and to which very feeble antagonists are provided :
the obturatores, the pyriformis, the g-emini and quadratus, the
pectinalis, and triceps, all assist in rolling the thigh-bone out-
wards ; whilst a part of the g-lutseus medius and minimus, and
the tensor vaginae femoris, are the principal agents of rotation
inwards. It has been denied that this eversion is caused by the
muscles, and it has been attributed to the mere weight of the
limb ; but any one may satisfy himself that it arises chiefly from
the muscles, by feeling' the resistance which is made to any
attempt at rotation of the thigh inwards. This difllculty is also
in some measure attributable to the length of the cervix femoris,
which remains attached to the trochanter major ; because in
p
106 FRACTURES OF THE UPPER PART
proportion to its length, by resting against the ilium, the tro-
chanter is prevented from turning forwards.
Directly that the bed-clothes are removed, two circumstances
strongly arrest the attention of the surgeon : namely, the dimi-
nished length of the injured limb, and the eversion of the foot
and knee. In the dislocation upwards, the head and neck of the
bone prevent the trochanter from being drawn backwards, whilst
the broken and shortened neck of the thigh-bone, in fracture of
this part, readily admits it ; and hence the reason that the foot
is inverted in luxation, and everted in fracture. It is, however,
proper to state, that an exception to this rule does now and then
exist, and that the limb is found inverted ; but it is of extremely
rare occurrence. Some hours must elapse before this eversion
assumes its most decisive character, as the muscles require some
time to assume a determined contraction ; and this is the reason
that the accident has been mistaken for dislocation on the dorsum
ilii. The surgeon having been called soon after the accident
has happened, before the muscles had acquired that state of
contraction to which they are liable, is led to mistake the nature
of the injury, because the foot is not so decidedly everted as it
afterwards becomes; and for this reason patients, even in hospital
practice, have been exposed to useless and painful extensions.
De^ee of In fractures of the neck of the bone within the ligament, the
patient, when perfectly at rest in the horizontal posture, suffers but
little; but any attempt at rotation is attended with some pain,
because the broken extremity of the bone then rubs against the
inner surface of the capsular ligament, upon which it is drawn by
the action of the muscles. The pain is felt in this accident in the
pain
OF THE THIGH-BONE. 107
upper and inner part of the thigh, opposite to the insertion of the
iliacus and psoas muscles into the trochanter minor, or sometimes
just below this point.
The perfect extension of the thigh may be easily effected, but Degree of
flexion is more difficult, and somewhat painful ; and its degree
depends upon the direction in which the limb is bent ; for if the
flexion be outwards, it is accomplished with but little comparative
suffering ; but if the thigh be directed towards the pubes, the act
of bending the limb is with difficulty accomplished, and is attended
with greater pain ; for it is easier or more difficult, in proportion
as the neck of the bone is shorter or longer.
In this accident the trochanter major is drawn up towards the situation of
... Ill 1^11 IT 1 1 ^^^ trochan-
ihum, but the broken neck of the bone attached to the trochanter tei major.
is placed nearer the spine of the ilium than the trochanter itself,
in which situation it afterwards remains ; and this alteration of
position makes the trochanter project less on the injured side,
because it is no longer supported by the neck of the bone, as in its
natural state, but rests in close apposition with the edge of the
acetabulum, and is, consequently, much more concealed than
usual, until the muscles waste from the duration of the injury,
when it can be distinctly felt upon the dorsum ilii; but there will
be a greater or less projection of the trochanter, proportioned to
the length of the fractured cervix attached to it.
If doubt exist of the nature of the accident, let the patient Appearance
I'i'i -1 • '" ''"' erect
be directed to stand by his bed-side, supported by an assistant, position.
and to bear his weight upon the sound limb ; the surgeon then
observes the shortened state of the injured leg ; the toes rest
upon the ground, but the heel does not reach it ; the knee and
P2
108 FRACTURES OF THE UPPER PART
foot are everted; and the prominence of the hip is diminished.
The least attempt to bear upon the injured limb is productive of
pain, which seems to be occasioned by the tension of the psoas,
iliacus, and obturator externus muscles, in the attempt, as well
as by the pressure of the broken neck of the bone against the
interior surface of the capsular lig-ament.
Crepitus. A crepitus like that which accompanies other fractures might
be expected to occur in this accident, but it is not discoverable
when the patient rests on his back with the limb shortened ; if,
however, the leg be drawn down, so as to bring the limbs to the
same length, and rotation be then performed, the crepitus will
be observed, as the broken ends of the bone are thus brought into
contact; but the rotation inwards most easily detects the fracture.
When the patient is standing on the sound leg, with the fractured
limb unsupported, by rotating it inwards, the crepitus will some-
times be perceived, as the weight of the limb brings the broken
bones nearer in apposition.
More fre- Womcn arc much more liable to this species of fracture than
quent in
women. nicu : wc rarely in our hospitals observe it in the latter, but our
wards are seldom without an example of it in the aged female.
The more horizontal position of the neck of the bone, and the
comparative feebleness of the female constitution, are the probable
reasons of this peculiarity.
To the circumstances I have already mentioned, as strongly
characterizing this accident, must be added the period of life at
which it usually occurs ; for the fracture of the neck of the thigh-
bone within the capsular ligament, seldom happens but at an
advanced period of life, whilst the other fractures which I have
OF THE THIGH-BONE. 109
to describe happen at all periods: and hence has arisen the great
confusion with respect to the nature of this injury ; for we find
that surgeons of the hig-hest character have confounded fractures
external to the capsular ligament with those which are within the
articulation; and mention the latter as occurring at a period of
life in which they scarcely ever happen.* It has been also said,
that in early life these bones will readily unite; an assertion which
I notice only to shew the confusion which has arisen on this
subject.
Old age, however, is a very indefinite term ; for in some it is as
strongly marked at sixty, as in others at eighty years. That
regular decay of nature which is called old age, is attended with
changes which are easily detected in the dead body ; and one of
the principal of these is found in the bones, for they become changes
thin in their shell, and spongy in their texture. The process of
absorption and deposition varies at different periods of life ; in
youth the arteries, which are the builders of the body, deposit
more than the absorbents remove, and hence is derived the great
source of its growth. In the middle period of life the arteries and
absorbents preserve an equilibrium of action, so that, with a due
portion of exercise, the body remains stationary; whilst in old age
the balance is destroyed, because the arteries act less than the
absorbents, and hence the person becomes diminished in weight ;
but more from a diminution of the arterial than from an increase
of the absorbent action. This is well seen in the natural changes
* I allude particularly to Dessault.
age in the
bones.
no FRACTURES OF THE UPPER PART
of the bones, their increase in youth, their bulk, weight, and little
comparative change during the adult period, and the lightness
and softness they acquire in the more advanced stages of life ;
hence the bones of old persons may be cut with a pen-knife, which
is incapable of making any impression on those of adults. Even
the neck of the thigh-bone in old persons is sometimes under-
going an interstitial absorption, by which it becomes shortened,
altered in its angle with the shaft of the bone, and so changed
in its form as to give an idea, upon a superficial view, that it
has been the subject of fracture, thus leading persons into the
erroneous supposition, that the bone has been partially broken
and re-united ; but it requires very little knowledge of anatomy
to distinguish in the skeleton, the bone of advanced age from
that of the middle period of life.
Age at The ae'e at which fractures of the neck of the thig-h-bone
within the capsular ligament generally occur, is a most important
consideration ; and as it is one on which the practice of the
surgeon very much hinges, I shall take the liberty of making the
following statement.
I have now been thirty-nine years at St. Thomas's and Guy's
Hospitals ; and, for thirty years, have had more than my share,
and much more than I merited, of the practice of London. We
have eight hundred and fifty patients in our two hospitals ; and I
believe that in the two hospitals, eight cases of fractures of the
upper part of the thigh-bone occur in each year ; but in order to
avoid exceeding the average number, I will consider them only
as five per annum ; thirty-nine multiplied by five, produce one
hundred and ninety-five ; add to these one case only in each year.
which it
OF THE THIGH-BONE. Ill
in my private practice of thirty years, they will collectively amount
to two hundred and twenty-five cases ; now, in that time, I have
only known tivo cases of fracture of the neck of the thigh-bone
within the capsular ligament occur under fifty years of age ; one
was in a patient aged thirty-eight, who had an aneurism of the
iliac artery; and the other has been kindly shewn tome by that
excellent anatomist, Mr. Herbert Mayo.
This fracture, then, rarely occurs under fifty years of age ; and
dislocation seldom at a more advanced period, although there are
exceptions to this rule; for I have myself once seen the fracture at
thirty-eight years of age, but it was very oblique; and a dislo-
cation of the thigh at sixty-two ; but between fifty and eighty
years is the period at which the fracture most usually occurs; for
from the different state of the bone, the same violence which
would produce dislocation in the adult, occasions fracture in old
age. But when dislocation does occur between sixty and seventy
years, it is in persons whose constitutions are particularly strong,
and in whom age has not produced those changes in the bones
which I have already endeavoured to point out.
That this state of bone in old age tends much to the production slight cause
of fractures, is shewn by the slight causes which often occasion this fracture.
them. In London, the accident most frequently occurs when
persons, walking on the edge of the elevated foot-path, slip upon
the carriage pavement ; though the descent be only a few inches,
yet, being sudden and unexpected, and the force acting perpen-
dicularly, with the advantage of a lever in the cervix, it produces a
fracture of the neck of the thigh-bone; and as a fall is the conse-
quence, the fracture is imputed, by ignorant persons, to the fall.
112 FRACTURES OF THE UPPER PART
and not to its true cause. Other trivial accidents may occasion
the misfortune. I was informed by a person who had sustained
a fracture of this kind, that being at her counter, and suddenly
turning to a drawer behind her, some projection in the floor
caught her foot, and preventing its turning with the body, the
neck of the thigh-bone became fractured. A fall upon the tro-
chanter major will also produce it ; but I have dwelt particularly
on the slight causes by which it is occasioned, that the young
surgeon may be upon his guard respecting it, as he might other-
wise believe that an injury of such importance could scarcely
be the result of a slight accident, and that excessive violence is
necessary to break the neck of the thigh-bone ; such an opinion
is as liable to be injurious to his reputation, as the error of
confounding this accident with dislocation.
Much difference of opinion has existed upon the subject of
the union of the fractured neck of the thigh-bone : it has been
asserted that these fractures unite like those of other parts of
the body; but the dissections which I made in early life, and the
opportunities I have since had of confirming these observations,
have convinced me, that fractures of the neck of the thigh-bone, —
those of the patella, — olecranon, — and condyles of the os humeri,
— and that of the coronoid process of the ulna, generally unite
by ligament, and not by bone. This principle I have taught in
my lectures for thirty years; and it is a most essential point,
as it affects the reputation of the surgeon. I was called to a
case of this fracture, in which the medical attendant had been
promising, week after week, an union of the fracture, and the
restoration of a sound and useful limb. After many weeks, the
Union of this
fracture.
OF THE THIGH-BONE. 113
patient became anxious for further advice : I did all in my power
to lessen the erroneous impression which had been made, by
telling the patient that she might ultimately walk, although
with some lameness : and taking the surgeon into another room,
asked him upon Avhat grounds he Avas led to suppose there would
be union, to which he replied, he was not aware but that the
fracture of the neck of the thigh-bone would unite like those of
other bones of the body ; the case, however, proved unfortunate
for his character, as this patient did not recover in the usual
degree.
Young medical men find it so much easier a task to speculate
than to observe, that they are too apt to be pleased with some
sweeping conjecture, which saves them the trouble of observing
the processes of nature ; and they have afterwards, when they
embark in their professional practice, not only every thing still to
learn, but also to abandon those false impressions which hypothesis
is sure to create. Nothing is known in our profession by guess ;
and I do not believe, that from the first dawn of medical science
to the present moment, a single correct idea has ev^er emanated
from conjecture: it is right, therefore, that those who are studying-
their profession, should be aware that there is no short road to
knowledge ; that observations on the diseased living, examinations
of the dead, and experiments upon living animals, are the only
sources of true knowledge; and that inductions from these are
the sole basis of legitimate theory.
In all the examinations which I have made of transverse frac-
tures of the cervix femoris entirely within the capsular ligament.
Q
114 FRACTURES OF THE UPPKR PART
I liave never met with one in which a bony union had taken place,
or which did not admit of a motion of one bone upon the other.
To deny the possibility of this union, and to maintain that no
exception to the g-eneral rule can take place, would be presump-
tuous, especially when we consider the varieties of direction in
which a fracture may occur, and the degree of violence by which
it may have been produced; as, for example, when the fracture
is through the head of the bone,* and there is no separation of
the fractured ends ; or, when the bone is broken without its
periosteum being torn ; or, when it is broken obliquely, partly
within and partly externally to the capsular ligament ; but I
wish to be understood to say, that if it ever does happen, it is
of extremely rare occurrence, and that I have not yet met with
a single decisive example of it.f As a proof that the general
principle which I have stated is correct, I subjoin the following-
account of forty-three cases, from different collections, of non-
union by bone, in fractures of the neck of the thigh-bone: —
* Mucli trouble has been taken to impress the minds of the public with the idea, that I have in my
Work on Dislocations and Fractures denied the possibility of union of the fracture of the neck of the
thigh-bone, and therefore I beg at once to be understood, that I believe the reason that fractures of the
neck of the thigh-bone do not unite is, that the ligamentous sheath and periosteum of the neck of the
bone is torn through, and that there is, in consequence of this circumstance, a want of nourishment
of the head of the bone; but I can readily believe, that if a fracture should happen without the reflected
ligament being torn, that as the nutrition would continue, the bone might unite; but the characters
of the accident would diflcr; the nature of the injury could scarcely be discerned, and the patient's
bone would unite with little attention on the part of the surgeon.
t In Mr. Cross's account of his visit to the French hospitals, some interesting matter upon this
sul)jcct will be found.
OF THE THIGH-BONE. 115
In the collection at St. Thomas's
In the College of Surgeons
In St. Bartholomew's
At Dublin . . _ . .
In Mr. Langstaff's, of Basinghall-street
In Mr. Bell's and Mr. Shaw's
In Mr. Brookes's _ - -
In Dr. Monro's - - - -
Mr. Mayo's collection
- 7
- 1
specimens
ditto.
- 6
ditto.
- 12
ditto.
- G
ditto.
-. «
ditto.
- 2
ditto.
- 2
ditto.
- 1
ditto.
43
To these I have to add another, from an experiment upon
a living animal ; while, upon the opposite side of the question?
only a single instance, upon which the mind can for a moment
dwell, has yet been produced; and in this case the same ap-
pearances were found in both the thigh-bones, and even these
resembled what I have several times observed in the dead body,
arising from a softened state of the bones. I have given a plate
of some of these appearances, and the preparations I shall at
all times be happy to shew to any of my professional brethren
who may wish to see them.
Having thus explained what is the common result of these cause of
thfc want of
cases in relation to their want of union, I shall now proceed to ""'O"-
state the reasons which may be assigned for the absence of ossific
union in the transverse fracture of the neck of the thigh-bone
within the capsular ligament. wantofpro-
The first reason is the want of proper apposition of the bones ; {ion. '"^^'^"
Q, 2
116 FRACTURES OF THE UPPER PART
for if their broken extremities in any part of the body be kept
much asunder, ossific union is prevented.
In a boy, who had a compound fracture of the tibia, without
the fibula being broken,* and who had the protruded end sawn
ofi\ the two extremities were prevented from coming in contact
by the fibula, and union never occurred. My friend, Mr. Smith,
an excellent surgeon, at Bristol, had a similar case under his care,
in which a portion of the tibia having been sawn ofi*, the fibula,
remaining whole, prevented ossific union. -f-
This fact is easily seen by experiments on animals : I sawed
seven-eighths of an inch of the radius from a rabbit, and the ends
of the bones were not united to each other, but only to the ulna*
I also sawed oflf the extremity of the os calcis, and suffered it to
be drawn up by the action of the gastrocnemius muscle, and it
united only by ligament. (See j)lates.)
* If the fibula be broken, large pieces of the tibia will separate, and yet ossific union will ensue.
+ The particulars of the Case were as follow; — The boy was admitted into the Bristol Infirmary
for disease of the tibia : and the diseased portion not exceeding more than from two to three inches
in length, that part of the bone was removed by the saw. In a month the limb had acquired so much
firmness, that the boy was permitted to walk about the ward, which he was able to perform tolerably
well, and in six weeks no doubt was entertained that ossification had taken place in the uniting
substance; at this time he sickened with the small-pox and died. — Upon examination, the edges of
the extremities of the tibia were found absorbed and rounded, and on the inferior portion, a bony
callus had formed, about three quarters of an inch in extent; no ossific matter was discoverable in the
greater part of the space originally occupied by the diseased bone, but a tough though thin ligamentous
band extended from the superior to the inferior portion of the tibia. — See Medical Records and
Researches.
OF THE THIGH-BONE. 117
The following' communication is from Mr. Benjamin Bell, of
CASE.
Edinburgh.*
26, St. Andrew Square, Edinburgh ;
August 7 til, 1823.
My dear Sir,
Excuse the freedom I take in communicating to you the
outline of a case, the result of which I had an opportunity of
observing a short time ago — as it is connected with the subject
so admirably developed in your late valuable publication, it may,
perhaps, prove interesting. In the progress of a tour through
some parts of Cumberland last month, I had occasion to visit
Whitehaven; Mr. Fox, an able and intelligent surgeon, of that
place, was so kind as to shew me the case alluded to. He was
also so good as to favour me w4th an account of its progress.
June, 1822. — William Coulthard, aged thirty-five, of a plethoric
habit, a miner, while stemming a bore, preparatory to blasting a
rock, the powder, in consequence of the friction, inflamed, and
exploding, gave rise to the foUowmg accident : — One portion of
the rock struck him in the perineum, and occasioned a compound
fracture of the tuberosity of the left ischium, which was followed
by profuse haemorrhage. Another portion of the rock came in
contact with the left leg, about four inches below the knee, and
* A highly respectable and intelligent individual ; grandson of Mr. Benjamin Bell, who was a
most useful man to the profession bj his publications : and son of Mr. George Bell, also a most able
surgeon, of Edinburgh. — Mr. Bell is likely to be a worthy successor to such a father.
118 FRACTURES OF THE UPPER PART
shattered the tibia and fibula. Four large loose pieces of bone
were extracted, by Mr. Fox, immediately after the accident.
These portions, when united, formed about sia^ inches of the entire
cylinder of the tibia. The sides of the wound were then drawn
together, and retained "in situ" by adhesive plasters. The limb
was placed in a proper position, and secured by pads and wooden
splints. In a short time the wound in the leg healed up ; three
months, however, after it had healed, an abscess formed, and
another small portion of bone came away, probably a part of the
fibula. The wound healed again without any untoward symptom.
The day on which I saw him (July 22nd, 1823), the leg in
which the injury had occurred appeared to be about two inches
shorter than the other. A large cicatrix occupied the fore and
middle part of the shin ; the patient could extend the leg and
stamp on the floor with considerable force ; the muscles were
plump and firm ; but the leg was to a certain extent flexible, and
could be slightly bent by the hands in four different directions :
backwards, forwards, to the right and to the left, on seizing it
below the knee (and above the fracture), and at the ancle. He
suflfered no pain, and permitted the liinb to be freely handled,
but could not, at that time, bear the whole weight of the body
upon it. It seemed to me as if the space between the two ends
of the fractured bones had been filled up with a sort of ligamento-
cartilaginous matter, resembling that found in cases of fracture
of the neck of the femur external to the ligament, or in that
occurring in illtreated cases of transverse fracture of the patella.
Whether that conjecture be right or not, it is difficult to determine.
A number of small pieces of bone have been extracted from the
OF THE THIGH-BONE. 119
wound in the perineum, and a pretty large loose portion can be
felt at present with the probe. In other respects the man's health
is good, and he expresses an anxious desire to return to his
work.
Your much obliged,
And sincerely grateful Pupil,
Benjamin Bell.
The neck of the thigh-bone when broken, is placed under
similar circumstances ; for, by the contraction of the muscles, it is
no longer in apposition with the head of the bone, and is, there-
fore, prevented from uniting; but, if this were the only obstacle,
it would be argued that the retraction of the thigh-bone might be
prevented by bandaging and extension, the truth of which cannot
be denied; but it is scarcely possible, even for a few hours, to
preserve the limb in exact apposition, as the patient, on the
slightest change of position, produces instant retraction, by
bringing into action those powerful muscles which pass from
the pelvis to the thigh-bone.
So in fractures of the patella, although we often do all in our
power to prevent retraction of the muscles, yet it very rarely
happens that we are able to support a complete approximation of
the bones.
The second circumstance which prevents a bony union in these Absence of
continued
fractures is, the want of pressure of one bone upon the other, even pressure.
if the length of the limb were preserved ; and this will operate in
preventing an ossific union in cases where the capsular ligament is
120 FRACTURES OF THE UPPER PART
not torn; and in all those which I have had an opportunity of
examining, it has not heen lacerated. The circumstance to which
I allude, originates in the secretion of a quantity of fluid into
the joint; from the increased determination of hlood to the
capsular ligament and synovial membrane ; a superabundance of
serous synovia, — that is, synovia much less mucilaginous than
usual, — extends the ligament, and thus entirely prevents the
contact of the bones, by pushing the upper end of the body of
the thigh-bone from the acetabulum. After a time this fluid
becomes absorbed, but not until the inflammatory process has
ceased, and ligamentous matter has been eff'used into the joint
from the interior of the synovial surface. The muscles, also,
do not in this accident produce pressure between the broken
extremities of bones, which so greatly conduces to the union
of other fractures ; for if two broken bones overlap each other,
on that side on which they are pressed together, there is an
abundant ossific deposit ; but on the opposite side, where there
is no pressure, scarcely any change is observed. So also we
find that, if the ends of the bone be drawn from each other by
the action of muscles, as sometimes happens in the fractures of
the OS femoris, tibia, os humeri, radius and ulna, union is not
effected until the surgeon, by a strong leathern bandage tightly
buckled around the limb, compels the bones to press upon each
other, and thus support the necessary inflammation for the pro-
duction of ossific union. When a fracture occurs amidst muscles,
those which are inserted into the fractured part of the bone, have
generally a tendency to keep the extremities of the bones toge-
ther, with some few exceptions ; but when a fracture occurs in the
OP THE THIGH-BONE. 121
neck of the thigh-bone, the muscles have only an influence upon
one portion of the fractured bone ; and this influence serves to
draw one part from the other.
But the third and principal reason which may be assigned for Lutie action
^ ^ ^ ^ . in the head
the want of union of this fracture is, the almost entire absence of of the bone.
ossific action in the head of the thigh-bone when separated from
its cervix ; its life being supported by the ligamentum teres,
which has only a few minute vessels, ramifying from it to the
head of the bone. The structure of the neck of the thigh-bone,
and of the parts surrounding it, is explained in the account of
the anatomical plate connected with this part of my subject.
But here it may be observed, that the neck and head of the
thigh-bone are naturally supplied with blood by the periosteum
of the cervix, and that when the bone is fractured, if, as most
frequently happens, the periosteum be torn through, the means
of ossific action are, in consequence of such fracture and lace-
ration, necessarily destroyed in the head of the bone. Scarcely
any change, therefore, takes place in the head or neck of the
bone attached to it ; no deposite of cartilage or bone, similar to
that of the other fractured bones, is produced ; but the deposite
which does take place, as will be seen in the plates of fracture
of the neck of the thigh-bone, consists of ligamentous matter,
covering the surface of the cancellated structure with little
patches like ivory on the head of the bone.*
The appearances which are found on the dissection of these thisfracture.
* But if 1 attempt to prevent union in a fracture external to a joint, by moving the bone from
time to time, I find that in proportion to that motion, is the quantity of callus produced, which is just
the reverse in the accidents I am now describing.
R
122 FRACTURES OF THE UPPER PART
injuries are as follow : — the head of the bone remains in the
acetabulum attached by the ligamentum teres. There are, upon
parts of the head of the bone, very small white spots like ivory.
The cervix is sometimes broken directly transversely, at others
with obliquity. The cancellated structure of the broken surface
of the head of the bone and of the cervix, is hollowed by the
occasional pressure of the neck attached to the trochanter, and
consequent absorption ; and this surface is sometimes partially
coated with a ligamento-cartilaginous deposite. The cancelli are
rendered firm and smooth by friction, as we see in other bones
which rub upon each other when their articular cartilages are
absorbed. Portions of bone are formed or broken oif, and these
are found either attached by means of ligament, or floating
loosely in the joint, covered by a ligamentous matter ; but these
pieces do not act as extraneous bodies, so as to excite inflamma-
tion, and thus produce their discharge, any more than those loose
portions of bone covered by cartilage, which are found so fre-
quently in the knee, and sometimes in the hip and elbow joints.
With respect to the neck of the bone which remains attached to
the trochanter major, the most remarkable circumstance is, that
it soon becomes in a great degree absorbed, leaving but a small
portion of it remaining ; its surface is yellow, and extremely
smooth, if the bones have rubbed against each other. Some
ossific deposition I have seen manifested around this small re-
maining part of the neck of the bone, and upon the trochanter
major and thigh-bone below it, in some examples of this fracture.
We do not, however, observe the same process of union as in
other bones, but a ligamentous instead of an ossific union.
OF THE THIGH-BONE. 123
The capsular ligament enclosing* the head and neck of the Ligament
bone becomes much thicker than natural, but the synovial mem- membrane.
brane underg'oes the greatest change from inflammation, being
very much thickened, not only upon the capsular ligament, but
also upon the reflected portion of that ligament upon the neck
of the bone, as far as the edge of the fracture.
Within the articulation is found a large quantity of serous ^^^i'nt'°*°
synovia ; by which term I mean to express, that the synovia is less
mucilaginous, and contains more serum than usual, mixed with a
small quantity of blood; this fluid, by gradually extending the
ligament, separates for a time one portion of bone from the other;
it is produced by the inflammatory process, and becomes absorbed
when the irritation in the part subsides. I do not know the exact New uga-
* ment.
period at which this change takes place, but I have seen it in the
recent state of the injury. Into this fluid is poured a quantity
of ligamentous matter, by the adhesive inflammation excited in
the synovial membrane, and flakes of it are found proceeding
from its internal surface, uniting it to the edge of the head of
the bone. Thus the cavity of the joint becomes distended, in
part by an increased secretion of synovia, and in part by the solid
effiision which the adhesive inflammation produces: the membrane
reflected on the cervix femoris is sometimes separated from the
fractured portions, so as to form a band from the fractured edge
of the cervix to that of the head of the bone ; bands also of union by
!• n I' 1 ligament.
ligamentous matter pass from the cancellated structure of the
cervix to the head of the bone, serving to unite, by this flexible
material, the one broken portion of bone with the other.
The trochanter is drawn up, more or less, in different accidents;
R 2
124 FRACTURES OF THE UPPER PART
and in those cases in which it is very much elevated, I have
known a considerable ossific deposite take place upon the body
of the thigh-bone, between the trochanter major and the tro-
chanter minor. When the bone has been macerated, its head
is much lighter and more spongy than in the healthy state,
excepting on those parts most exposed to friction, where it is
rendered smooth by the attrition, which gives it a polished surface.
These then are the usual appearances on dissection ; but there
are two preparations in the Royal College of Surgeons in London,
which have been sent as specimens of union by bone of the cervix
femoris ; but as I may be thought prejudiced in favour of the
opinion I have advanced, I shall give that of an excellent anatomist
whose loss we have had lately to deplore. Mr. Wilson says,
" / have examined very attentively these two preparations, and
cannot perceive one decisive proof in either, of the bones having
been actually fractured"
This circumstance, of want of ossific union, is not peculiar
to the neck of the femur, as will be seen in our account of
fractures of the condyles of the os humeri, of the coronoid
process of the ulna, and of bones generally, when seated within
the capsular ligament.
It appears, then, as a general principle, from the account which
I have given of the dissection of those whose bodies have been
examined after having suffered from this fracture, that ossific
union is not produced ; that nature makes slight attempts for its
production upon the neck of the bone, and upon the trochanter
major, but scarcely any upon the head of the bone ; and that if
imion be produced, it is by means of ligament.
OF THE THIGH-BONE. 125
Mr. Stanley, for whom I have g-reat respect, hoth as an anato-
mist and a surgeon, has met with the appearance of fracture
in the neck of each thigh-bone, in the same subject. I do
not mean to deny the possibiUty of the necks of both thigh-bones
in this subject having been fractured, because that point can
only be determined by the history of the accident, and by a very
careful and accurate examination of several sections of the bones ;
but I can shew that similar effects are produced by disease.
The neck of the thigh-bone in adult persons of middle age, has
a close cancellated structure, with considerable thickness of the
shell which covers it ; but in old subjects, the cancellated struc-
ture of the shaft of the bone, which is formed of a coarse net-work,
loaded with adipose matter, is often extended into the neck of the
bone, and the shell which covers it becomes so thin, that when
a section is made through the middle of the head and cervix, it
is found diaphanous; of this I have several specimens. As the
shell becomes thin, ossiiic matter is deposited on the upper side of
the cervix, opposite the edge of the acetabulum, and often a
similar portion at its lower part, and thus the strength of the bone
is in some degree preserved : this state may be frequently seen
in very old persons. Mr. Steel, of Berkhampstead, one of the
most intelligent surgeons, and most respectable men I know, gave
me the thigh-bone of a person thus altered, whose age was ninety-
three.
When the absorption of the neck proceeds faster than the deposite
on its surface, the bone breaks from the slightest causes, and this
deposite wears so much the appearance of an united fracture, that
it might easily be mistaken for it. Before the bone thus alters, we
126 FRACTURES OF THE UPPER PART
sometimes meet with a remarkable buttress shooting up from the
shaft of the bone into its head, giving it additional support to that
which it receives from the deposite of bone upon its external
surface. But another change is also produced from disease, of
which the following is the history, and which directly applies to
the subject before us : —
Old bed-ridden and fat persons (generally females), are often
brought into our dissecting-room with some of their bones
broken (and more frequently the thigh-bone than any other)
in being removed from the grave. If the cervix femoris of such
persons be examined, it will be found that the head of the bone
is sunken down upon its shaft, and that the neck of the thigh-bone
is shortened, so that its head is in contact with the shaft of the
bone opposite to the trochanter minor ; and at the part at which
the ligament is inserted into the neck of the bone, the phosphate
of lime is absorbed, and a ligamento-cartilaginous substance
occupies its place ; either extending entirely through the neck of
the bone, or partially, so that one section exhibits signs of it, and
in another it is wanting. The bone, in some cases, is so soft and
fragile, both in its trochanter and head, that it will scarcely bear
the slightest handling ; and the motion of the thigh-bones in the
acetabulum is almost entirely lost, so that the persons must have
had little use in their lower extremities.
During the last winter we had two instances of this alteration in
the neck of the bone, and it is an appearance which I have several
times seen.
In examining the body of an old subject, very much loaded
with fat, in the dissecting-room of St. Thomas's Hospital, I found
OF THE THIGH-BONE. 127
that the gentleman who had dissected one limb, had cut through
the capsular ligament of the hip-joint, and tried to remove the
head of the thigh-bone from the acetabulum ; but the neck of the
bone broke on the employment of a very slight force, and upon a
further trial to remove it, the bone crumbled under his fingers.
As the other limb was not yet dissected I requested Mr. South,
one of our demonstrators, to remove, with care, the upper part of
the other thigh-bone; but although he used great caution in doing
it, he could not remove the bone without fracturing the upper part
of its shaft ; but he succeeded in removing the upper part of
the bone, so that it might be preserved ; and of this I have
given plates.
We have here then a case in which the neck of the bone
was absorbed, so that the head was brought in contact with the
trochanter; in which, most decidedly, there had not been a frac-
ture, although it had in some parts the appearance of one ; and in
which, the disease occurred in each hip-joint.
Another case of the same kind was examined by Mr. South,
during the last winter, which, so far as relates to the softened
state of the upper part of the thigh-bone, was similar to the
former; the heads were spongy, the necks were shortened, so that
there was scarcely any remaining ; each trochanter was light in
weight, spongy, and very large; and there was little if any
motion in either of the hip-joints, so that both limbs appeared,
at first sight, as if dislocated upon the pubes.
But the best specimen of this state of the bone is the following,
which I preserve with the most assiduous care, and value in the
highest possible degree : — I have had for twenty years in the
128 FRACTURES OF THE UPPER PART
collection of St. Thomas's Hospital, the thigh-bone of an old per-
son, in which the head of the bone had sunken towards its shaft.
I have been in the habit of shewing this bone twice a year as a
specimen how bones sometimes become soft from age and disease,
and from the absorption of their phosphate of lime ; and I have
frequently cut with a penknife both its head and its condyles, to
shew this softened state. On sawing through its cervix, the
cartilage, deprived of its phosphate of lime, had dried away in
several parts, and the appearance was such that a person, ignorant
of the change, would have declared it to be a fracture ; only, that
in some sections the cartilage had taken different directions, and
in some the bone was not yet entirely absorbed. We have also
in the Museum of St. Thomas's Hospital, a skeleton in which
both the thigh-bones, and each os humeri, are, in a subject
extremely altered by rickets, divided by similar portions of car-
tilage, in which no ossific matter exists.
The plates which are appended will afford better ideas of these
morbid changes than words can convey ; and I hope Mr. Stanley,
also, will give plates of his preparations ; both, however, should
be engraved, as, without both, the public cannot form a correct
opinion.
I have been led to prosecute the inquiry by experiments upon
animals. I found it difficult to succeed in breaking the bone in
the direction I wished, and, after a great number of experiments,
was successful only in the following instances; the preparations
of these I have preserved, and they may be seen in the Museum
at St. Thomas's Hospital. {See pJate.)
OF THE THIGH-BONE. 129
Experiment I.
The neck of the thio^h-bone was fractured in a rabbit, on
October 28th, 1818 ; and on Decennber 1st, 1818, as the wound
had been some time healed, I dissected the animal.
Appearance on dissection. — The capsular ligament was much
thickened ; the head of the bone was entirely disunited from
its neck, but adhered by a new ligamentous substance to the
capsular ligament ; the broken cervix, which was very much
shortened, played on the head of the bone, and had smoothed
it by attrition ; the head of the thigh-bone had not undergone
any ossific change.
Eooperiment 11.
The neck of the thigh-bone was broken in a dog, November
18th, 1818, and the animal was killed on the 14th of December
following.
Dissection. — The trochanter was much drawn up by the action
of the muscles, so that the head and cervix femoris were not in
apposition. The capsular ligament was much thickened, and
contained a large quantity of synovia.
The joint was lined with adhesive matter of a ligamentous
appearance, adhering to the head of the bone, which did not
seem to be changed by any ossific process ; but the thigh-bone
around the capsular ligament, the trochanter major, and the
bone a little below it, were enlarged.
We find, therefore, by these dissections, that what appears in
the human subject after this accident, takes place also in other
s
130 FRACTURES OF THE UPPER PART
animals ; and that motion, want of apposition and pressure, with
the little ossific action in the head of the bone, under these cir-
cumstances, produce a deficiency of bony union, as in man.
The two preparations which I have preserved, were the only
examples in which the experiment was complete in relation to the
transverse fracture ; but I have two other interesting- preparations
derived from these experiments. I also made a great number of
others, in which the fractures continued compound; in each of
these the head of the bone either became absorbed, or was dis-
charged by ulceration ; and I never could succeed in uniting
the head to the neck of the bone. I have since divided the neck
of the thigh-bone in a dog, and the head of the bone was three-
fourths absorbed. By way of contrast I have also divided the
bone externally to the capsule, in five instances, and have pre-
served the bones ; the wounds united by adhesion, and every
bone has been healed by ossific union ; the natural inference is,
that fractures within the capsule, do not unite by bone, but that
fractures external to it, readily do so. As to the notion that
the bearing upon the limb, or its weight, may have influence to
prevent union in these animals, I have only to observe, that the
muscles become contracted, the limb drawn up, and the animal
cannot bear upon it for several weeks.
OF THE THIGH-BONE. 131
My friend, Mr. Brodie, has furnished me with the following
account of an experiment which he made upon the same subject,
which fully confirms my observations.
Dear Sir,
The circumstances of the experiment which I mentioned,
were briefly these : — The tibia of a g-uinea-pig" was broken at the
lower end. A month afterwards the animal was killed. On
dissection, I found a fracture extending across the tibia, trans-
versely, and so close to the ancle-joint, that it was situated at
that part of the bone which is covered by the reflected layer of
the synovial membrane. The synovial membrane itself, and the
ligaments of the joint, appeared to have been very little injured,
and the broken surfaces had remained in good apposition ; never-
theless, there was not the smallest union of them, either by bone
or ligament, and there had been no formation of callus round the
fracture. The bone in the neighbourhood of the fracture had
become compact and hard, in consequence of the ossification of
the medullary membrane lining the cancelli.
I am, dear Sir, your's truly,
Saville Row, B. C. Brodie.
August 16t7i, 1823.
Professor Burns, of Glasgow, has had the great kindness to
send me the following observations : —
"Permit me to offer my warmest thanks for the pleasure and
edification I have received from the study of your late work.
s2
132 FRACTURES OF THE UPPER PART
I was early led to attend to the process adopted by nature in
forming' a new articulation in injuries to the hip-joint, by the
dissection of a dog which I had when a boy, and which had the
hip fractured. Many years afterwards I examined the parts, and
found the fragment of the cervix belonging to the head absorbed,
the head itself filling the acetabulum ; the shaft of the bone
expanded, and a new head formed for a new socket, and the
Avhole enveloped in a dense capsule or covering.
" In a fracture of the os femoris external to the capsule, the
gluteus medius and minimus seem to act as a cushion to stop the
ascent of the end of the cervix, whilst the fragment attached to
its head will, perhaps, afford some opposition ; but in the fracture
within the capsule, the end of the cervix is drawn more freely
up under the gluteus medius, and lodged behind the inferior
spinous process of the ilium.
" Is this the explanation of the greater shortening in the one
fracture than in the other ?
" Nothing can better explain the want of ossific union than
the principle you have laid down."
John Burns.
Glasgoiv, 1823.
Having by experiment ascertained the circumstances I have
mentioned, I was next anxious to learn if the head and neck
of the thigh-bone would unite under a longitudinal fracture, in
part within and in part external to the capsular ligament, in
which apposition, contact, and pressure are maintained; and for
this purpose 1 made the following experiment : —
OF THE THIGH-BONE. 133
Experiment 111.
I divided the head, neck, and a portion of the trochanter major Longitudinal
fracture.
of the thigh-bone of a dog longitudinally, by placing a knife
on the trochanter major, and striking it down towards the
acetabidum through the head of the bone. The animal was
killed twenty-nine days after, and the following appearances
presented themselves : —
A portion of the trochanter major had been broken off, and
was only united by cartilage. The head and neck of the bone,
which had been longitudinally broken, were united ; the neck
by a larger quantity of ossific deposite than that which joined
the separated portions of the head of the bone, and so irregularly
as to make a beautiful preparation, and shew the circumstance
most clearly. (See plate.) This bone may be seen in the
collection at St. Thomas's Hospital.
Whether the union began in the fracture externally to the
ligament, and proceeded inwards, or whether on the whole surface
at once, it is impossible to ascertain ; but the coalescence was
firm, though, as I have stated, I thought more so at the neck
than at the head of the bone. The union in this case is readily
explained. Apposition was supported ; the vessels of the head
of the bone and cervix remained whole ; and, therefore, this
experiment shews at once why the longitudinal unites, and the
transverse, in general, does not.
Thus, then, it appears, that in a longitudinal fracture of the
head and neck of the bone 171 part external to the ligament,
if the bones be applied to each other, pressed together, and in uni.
a state of rest, and the vessels remain, ossific union can be
]34
FRACTURES OF THE UPPER PART
produced ; although the ossific deposition is extremely slight
when compared with that of other bones.
Diagnosis. Tlic fracturc of the neck of the thigh-bone may be confounded
with the dislocation of the os femoris upon the dorsum ilii ; with
that into the ischiatic notch ; and with that upon the pubes ; as
in all these luxations the limb is shorter. From the two former
it may be distinguished by the eversion of the foot, and by the
mobility of the limb in fracture ; and from the latter by the ball
of the OS femoris being felt in the groin in the dislocation on the
pubes ; otherwise the eversion of the foot in both cases might
lead to their being confounded.
Treatment. With rcspcct to the treatment of fractures of the neck of the
thigh-bone within the capsular ligament, various are the means
to which I have had recourse, and which I have known resorted
to by others, for the'purpose of producing union in this accident,
but all without avail.
One mode has consisted in placing the fractured limb over a
double inclined plane, by which a regular and constant extension
is preserved, and which, by raising the planes at the knee, may
be increased to any degree that the surgeon may require, or the
patient can bear ; at the same time, a bandage is applied around
the pelvis and upper part of the thigh, to bring the neck of the
bone, as much as possible in approximation with the head from
which it has been separated ; and this extension, with pressure,
has been steadily preserved for three months. With respect to
the patient's body, it has been placed at an angle of forty-five
degrees.
A second method has consisted in placing a board at the foot
OF THE THIGH-BONE. 135
of the bed, upon which the foot of the sound Umb is rested, so
as to prevent the descent of the body in the bed ; the other
limb is then extended as much as possible, and a weig'ht, appended
to the foot, is suffered to hang through a hole in the board over
the end of the bed, in order to support the extension with regu-
larity and steadiness for several weeks.
In a third method, the patient has been placed in bed with
both limbs extended to the utmost possible degree, and then the
tAvo feet have been bound together by a roller, passed from the
foot on the injured side under the sound foot, so as to make one
limb steadily preserve the extension of the other. Or this may be
effected by an iron plate fixed to the shoe on the sound foot,
with a screw passed through a hole in the plate, and having a
band fixed to the other foot, which may be tightened by turning
the screw, and the foot, by this means, be kept constantly
extended.
A fourth mode employed for this purpose has been the appli-
cation of Boyer's splint, with the intention of extending the limb
from the pelvis : but this splint, though it answers well for frac-
tures of the thigh under ordinary circumstances, has a tendency
to prevent union in those fractures which occur at the upper part
of the bone, by the pressure of its band upon the inner and
upper portion of the thigh.
Mr, Hagedorn has recommended a machine for fractures of
the neck of the thigh-bone, which is very ingenious in its con-
struction. It consists of a long splint to extend from the hip to
the foot, and which is to be firmly applied, by means of proper
straps, to the sound limb ; at the bottom of this is fixed a broad
136 FRACTURES OF THE UPPER PART
foot-boardj perforated with a sufficient number of openings to
receive the bands, by means of which both feet are to be securely
fixed to it ; these bandages are attached to a kind of leather
gaiter, made to lace tight round the ancle, and the upper part
of the splint is kept close to the hip by means of a broad bandage
carried round the pelvis. By this machine the extension of the
limb is tolerably well effected, so long as the patient can be kept
still ; but a displacement of the bones will invariably be the
consequence of every motion which the evacuation of the faeces
will necessarily require. I am never so wedded to any opinion
as to be prevented from trying, or from wishing others to employ,
every means which appear plausible or ingenious | and, there-
fore, I think that this instrument ought to have a fair trial.
Mr. Earle is of opinion, that these cases may be cured by long
continued attention in keeping the parts at perfect rest. I think
a trial should be made of the bed recommended by Mr. Earle,
and heartily wish him success in his laudable attempt to prevent
the lameness and shortening of the limb in cases of fracture
within the capsule ; which has invariably been the result in those
cases I have had an opportunity of witnessing.
But all the means which I have seen used have been found
unavailing. I have been baffled at every attempt to cure, and
have not yet witnessed one single example of union in this
fracture. I know that some persons still believe in the possibility
of this union, by surgical treatment, and that instances of success
have been published ; but I cannot give credence to such cases
until I see that the authors were aware of the distinction between
fractures within and external to the articulation.
OF THE THIGH-BONE. 137
The following anecdote was related to me by an intelligent
surgeon, who had been attending an hospital on the Continent
for some time. One of the surgeons belonging to it observed,
"Some of the English surgeons do not believe that we unite
fractures of the neck of the thigh-bone ; now there is one you
shall examine, as the patient is dying." A few days after, the
patient died, and the joint was examined, when the bone was
found still disunited. The surgeon of the hospital only made a
significant shrug of disappointment.
The cases in which union might be produced are two : one, in
which the periosteum, covering the neck of the thigh-bone, is not
torn through, a circumstance which now and then happens ; the
other, in which the head of the bone is broken, so that the cervix
still remains in the acetabulum : but in neither of these cases will
the limb exhibit the shortened state which the fracture of the neck
of the bone usually produces, and therefore the common cha-
racters of the accident will be wanting. Even in such cases, I
would prefer a ligamentous union, to the confinement and danger
of bony union, in regard to the health and life of the person, and,
as I believe, to the subsequent use of the joint.
Baffled in our various attempts at curing these cases, and find-
ing the patient's health suffering under the trials made to unite
them, I should, if I sustained this accident in my own person,
direct that a pillow should be placed under the limb throughout
its length ; that another should be rolled up under the knee, and
that the limb should be thus extended for ten days or a fortnight,
until the inflammation and pain had subsided. I should then
daily rise and sit in a high chair, in order to prevent a degree of
T
138 FRACTURES OF THE UPPER PART
flexion, which would be painful ; and, walking with crutches,
bear gently on the foot at first ; then, gradually more and more,
until the ligament became thickened, and the muscles increased
in their power. A high-heeled shoe should be next employed, by
which the halt would be much diminished. Our hospital patients,
treated after this manner, are allowed in a few days to walk with
crutches ; after a time a stick is substituted for the crutches, and
in a few months they are able to use the limb without any adven-
titious support.
The degree of recovery in these cases is as follows : — if the
patient be very corpulent, the aid of crutches will be for a long
time required ; if less bulky, a stick only will be sufficient ; and
where the weight of the body is inconsiderable, the person is
able to walk without either of these aids, but drops a little at each
step on that side, unless a shoe be worn having a sole of equal
thickness to the diminished length of the limb. In every case,
however, in which there is the smallest doubt whether it be a
fracture within, or external to, the ligament, it will be proper to
treat the case as if it were the fracture which I shall hereafter
describe, and which admits of ossific union.
It is gratifying to find opinions which have been for thirty years
delivered in my lectures, confirmed by the observations of intel-
ligent and observing persons; and, therefore, it was with pleasure
that I read in the Dublin Hospital Reports, the account of the
dissection of several cases of fracture of the cervix femoris, by my
friend, Mr. Colles, of Dublin (a man excellently informed in his
profession), who found in them similar want of ossific union, in
the fracture within the ligament, to that which I have described.
OF THE THIGH-BONE. ] 39
A few contributions of a similar kind, from the ardent cultivators
of morbid anatomy, would soon prevent persons from being
tortured with trials, which have been frequently repeated, and
found to be uniformly unavailing.
ADDITIONAL OBSERVATIONS ON FRACTURES OF
THE NECK OF THE THIGH-BONE.
The following Letters, which were appended to the former
editions of this work, I have embodied here ; each of them being
interesting in regard to the facts upon this subject. One from
I^fr. Stanley, Assistant-Surgeon of St. Bartholomew's Hospital,
and Demonstrator of Anatomy at that hospital ; one from Dr.
Monro, Professor of Anatomy at Edinburgh ; and the other from
Mr. Colles, Professor of Anatomy and Surgery at Dublin.
Lincolfis Inn Fields, February 2Dth, 1823.
My dear Sir,
We have in the Museum of St. Bartholomew's, twelve spe-
cimens of fractures in the neck of the thigh-bone ; six external
to the capsule, and united, and six within the capsule. In three
of the latter there is no union, and in the other three there is
union by ligamentous matter.
I remain, dear Sir,
Your's most respectfully,
Edward Stanley.
This letter shews the difference of fractures within and frac-
tures external to the ligaments, in regard to their union.
T 2
140 FRACTURES OF THE UPPER PART
Edinburgh, February \7tJi, 1823.
My DEAR Sir Astley,
In answer to your query respecting fracture of the neck of
the thigh-bone, I beg leave to inform you, that I have had an
opportunity of examining two cases only after death, and in both
of these, the broken ends of the neck of the bone were united by
a substance somewhat like to ligament.
I have seen several persons who had, during their lives, a
fracture of the neck of the bone, but in all of them a bony
re-union had not taken place.
In the catalogue of the Museum which was bequeathed to
the University by my father, mention is made of the fracture of
the neck of the thigh-bone which had re-united by a bony union.
Upon examining the preparation with attention, it appears to me,
that there had been no fracture, but a disease in the trochanter
major, and that a number of osseous speculse have shot upwards
within the capsular ligament, giving the appearance of an ill set
fracture.
Should you wish to have a drawing of this preparation, I shall
have great pleasure in sending it to you.
There is also a specimen in the Museum of a fracture of the
thigh, about four lines beyond the insertion of the capsular
ligament, at the root of the trochanter.
Your's, most truly,
Alexander Monro.
OF THE THIGH-BONE. 141
Stephen's Greeny February \Wi, 1823.
My dear Sir,
Since the receipt of your letter, I have carefully examined
all the specimens of fractures of the neck of the thigh-bone con-
tained in both Museums of our College of Surgeons. In that
which is appropriated to the use of the School, I find seven
instances of fracture within the ligament ; each of these have been
described in my paper on this subject, in the Dublin Hospital
Reports. Since the publication of that Essay, the conservator of
the College -Museum has collected five specimens of fracture
within the ligament. In this Museum are also four instances of
fracture external to the condyle ligament. In the School-Museum
are two instances of fracture external to the ligament. Of this
latter description of fracture, fewer than one half the number are
united by bony union. Of the fractures within the ligament, not
one has made a nearer approach to bony union than that described
in the paper alluded to. I must say, that I have never yet seen
an instance of bony union where the fracture had been within
the ligament. We have very many specimens of a disease of the
head and neck of the thigh-bone, which is of frequent occurrence
amongst our labouring poor. On this subject I have some idea
of writing a paper for the next volume of the Dublin Hospital
Reports, and of endeavouring to shew, that in all probability, the
supposed cases of fracture within the ligament united by bone,
Avere merely instances of this disease.
If you have any wish for them, I shall have great pleasure in
sending you sections of some of these cases, which I am certain
142 FRACTURES OF THE UPPER PART
might be passed upon many surgeons for fracture of the neck of
the bone.
1 am, my dear Sir,
Your most sincere Friend,
A. COLLES.
I have also seen three cases of this fracture in the dead body
since the publication of the second edition of this work.
First: — A very old female was brought into the dissecting-
room at St. Thomas's Hospital, whose right limb was everted,
and was an inch and a half shorter than the left. Upon dissec-
tion, the sciatic nerve had the appearance of having been bruised ;
a small portion of bone was broken off at the insertion of the
obturator externus muscle ; a similar portion of bone was sepa-
rated at the upper part of the insertion of the quadratus femoris.
The capsular ligament was torn at the part at which it is covered
by the iliacus internus muscle. The capsular ligament being
further opened, was found to contain a small fragment of bone ;
and it was filled with adhesive ligamentous matter, poured out by
inflammation, and adhering to the internal surface of the capsular
ligament, to the remnants of the cervix femoris, and, slightly, to
the head of the bone. The cervix femoris had been broken close
to the head of the bone, and entirely within the capsular ligament.
The head of the femur remained in the acetabulum unaltered,
excepting that its surface was partially covered by ligament. The
neck of the bone was so absorbed, that the portion of it which
remained was smaller than the trochanter minor. Its cancellated
structure was covered by the effused ligamentous matter. There
OF THE THIGH-BONE. 143
was not the slightest appearance of ossific union, or even of bony
deposite, although this injury must, from the changes produced
by inflammation, have happened from two to three months before
death. When I had raised the thigh-bone one inch and a half,
it was prevented from rising higher by the lower portion of the
gluteus minimus, and by the capsular ligament.
Second : — Mr. Clarke gave me a preparation made from the
body of a man, eighty-two years of age, tall and remarkably
strong for the time of life, who died eight weeks and four days
after having fractured the neck of the thigh-bone. Upon inspec-
tion, not the least attempt at ossific union was found. The liga-
mentous sheath of the cervix femoris was only partially torn.
Third: — Mr. Key, Surgeon to Guy's Hospital, gave me the
head and neck of the thigh-bone, taken from a subject brought
into the dissecting-room ; in which case, the neck of the thigh-
bone was absorbed. The head of the thigh-bone was entirely
detached from the cervix. No ossific process existed in the
cancelli of either the neck or head of the bone, but some ossific
deposite appeared around the insertion of the ligamentum teres.
I have a patient in Guy's Hospital at this time, with a fracture
of the neck of the thigh-bone, in whom the following circum-
stances are to be observed: — When placed in the recumbent
posture, the limb is one inch and a half shorter than the other ;
but when he is standing, the injured limb is two inches and a
half shorter than the sound limb : the cause of this contrariety is
as follows : — When he is recumbent, and the spinous processes
of the ilia are in the same line, the shortening is only from the
retraction of the thigh-bone ; but when he is standing, he throws
144 FRACTURES OF THE UPPER PART
the axis of his body into the thigh of the sound Umb, to enable
him to support himself; and elevating the pelvis, raises the
injured limb one inch more than when he is recumbent.
FRACTURES OF THE CERVIX FEMORIS EXTERNAL
TO THE CAPSULAR LIGAMENT, AND INTO THE
CANCELLI OF THE TROCHANTER MAJOR.
The symptoms of this accident in some respects resemble those
of the fracture within the ligament, and they require much
attention to distinguish them accurately ; but the result is entirely
different ; so that a favourable opinion may be given as to the
restoration of the bone by an ossific union.
Symptoms. j^ ^his accidcut, the injured leg is shorter than the other by
half to three quarters of an inch ; the foot and toe on that side
are everted, from the loss of support which the body of the thigh-
bone sustains in consequence of the fracture ; much pain is felt
at the hip, and on the inner and upper part of the thigh ; and the
joint loses its usual roundness.
Ss!'^"^ The distinguishing signs of this accident are,— First: — It some^
times occurs at the earlier periods of life; for it happens in the
young, and in the adult tinder fifty years of age, although I
have known it at a later period, when it often proves fatal ; but
if the above symptoms are seen at any age under fifty years, there
will be generally found a fracture external to the capsular liga-
bone. ment, and capable of ossific union. Several of these cases which
OF THE THIGH-BONE. 145
have fallen under my notice have occurred under that period ; and,
therefore, a surgeon called to the bed-side of a patient who has
an injury to the upper part of the thigh-bone, if he finds the age
of the patient to be under fifty years, will, with very few excep-
tions, be warranted in pronouncing it either a fracture just external
to the ligament, or one through the trochanter major. But I also
mention that both fractures occur in age, and, therefore, no
conclusion can be drawn between the two, in advanced age, but
by the most careful examination.
Secondly: — These cases may be in some measure distins^uished From severe
^ injuries,
by the severity of the accident which produces them ; for whilst
the internal fracture happens from very slight causes, this, on the
contrary, is produced either by severe blows, or falls upon the
edge of some projecting body, as against the edge of the curb-
stone, or from the pressure of laden carriages passing over the
pelvis. My experience has taught me, that a very slight accident
generally occasions the fracture within the capsule, and a violent
blow, or fall, the other: the first is an accident upon which the
fall often succeeds, the other is generally the consequence of that
fall ; many of those within the capsule which I have witnessed,
were produced by the person's slipping from the curb-stone to
the road-way,* — not that I mean to deny, that a fall will, and
does occasionally, produce a fracture within the capsule, or that
in a very old person, a fracture may occasionally happen in any
* Slipping from the curb-stone to the road- way produces a violence in the perpendicular direction i
falling against the edge of the curb-stone often produces the fracture external to the capsule.
W
146 FRACTURES OF THE UPPER PART
part of a bone, from a slight cause compared with that which
produces it in the young.
Crepitus. Thirdly: — It may be generally known by the crepitus which
attends it upon slight motion, for it is unnecessary to draw down
the limb, to distinguish the grating of one bone upon the other,
and this arises from the less retraction of the limb.
Fourthly : — Great ecchymosis often attends it.
Swelling. Fifthly: — Swelling and tenderness to the touch quickly succeed
upon the upper part of the thigh, from the inflammation which
this injury produces.
Severe pain. Sixthly: — Tliis accidcut is generally marked by much greater
severity of suffering than the fracture within the ligament, slight
motion producing excruciating pain, which does not happen in
an equal degree in the fracture within the ligament.
Seventhly : — There is a high degree of irritative fever, and many
months elapse before the patient recovers any use of the limb.
Upon dissection of these cases, the seat of the fracture is
found to vary very much in different examples, being more or
less complicated, but it is external to the capsular ligament ;
and the fracture is placed at the neck of the root of the thigh-
bone, the trochanter is split, and the neck of the bone is received
into its cleft. The trochanter major is often broken into several
portions.
We have few opportunities of dissecting these cases in the
young, because they recover from the accident, and, therefore,
the examination of them has been most frequently made in aged
persons, whom they often destroy. The following cases will
explain the appearances on dissection.
Dissection.
OF THE THIGH-BONE. ]47
Mr. Powell, surgeon, of Great Coram Street, presented me
with a valuable preparation, taken from a patient of his who
died fifteen months after the accident, and the following* is the
history of the case.
Fracture of the Neck of the Thigh-bone.
CASE I.
Mary Clements, aged eighty-three and a half years, when walk-
ing across her room, October 1st, 1820, supported by her stick,
which from the debility consequent upon old age she was obliged
to employ, unperceived by herself, placed her stick in a hole of the
floor, by which, losing her balance, and tottering to recover
herself from falling, which she would have done but for those
near her, she found she had, as she supposed, dislocated her
thigh-bone. When called to her, she was lying upon her bed, in
much pain, with the thigh shortened, and the foot everted. Sus-
pecting the nature of the accident, I directed extension to be
made by the foot, which I found was readily brought to corres-
pond with the opposite side ; and upon rotating the limb I
discovered a crepitus, which fully confirmed me in the opinion
that some part of the neck of the femur was broken. With a
view to the union of the bone, I first placed the limb in a straight
position, making a permanent extension by fixing the pelvis and
extending from the ancle ; but as the mental faculties were
nearly as much shaken as the corporeal, and she could not be
induced to keep up the extension required, I was obliged after
a few days to change my plan for that of two boards united
w 2
148 FRACTURES OF THE UPPER PART
together at right angles, over which the thigh was placed, and
was supported by pillows kept in their position by lateral pegs.
In a very few days this position, in which she at first expressed
herself comfortable, became so irksome, that she would no longer
submit to it, and I was obliged again to abandon my wish to be
decidedly useful to her. From this period she adopted any
position that was most comfortable to herself, but generally as
the easiest state, lay upon the same side as the accident, with the
limb drawn up at nearly right angles with the body. The neigh-
bourhood of the joint, in the early stage of the accident, was
kept wet with an evaporating lotion ; the regular action of the
bowels was elicited by occasional aperients, and she generally
took at bed time, for an old chronic cough, an anodyne pill.
For some weeks I found that I could extend the limb when I
wished, but afterwards I could not accomplish this, I supposed
from the permanent contraction of the muscles of the pelvis ;
this I presumed was more especially the case, as the opposite
thigh was bent at the same angle, and was equally immove-
able. As she was become perfectly bed-ridden, to which state
of imbecility she might be said to be rapidly approaching even
before the accident, she had sloughing of the integuments of
the parts upon which she lay, but did not suflfer other incon-
venience. Her general health appeared nearly as good as before
the accident ; and she ultimately sunk without any symptom of
active disease, about fifteen months from the period at which
the fracture took place.
Inspection.
The limb was drawn up at right angles with the body, or
' OF THE THIGH-BONE. 149
nearly so. I removed the os innominatiim with the thigh-bone,
and presented them to Sir Astley Cooper, and the following is
the account of the dissection.
Dissection.
The neck of the thigh-bone had been broken at its junction
with the body of the bone, and had been forced into the can-
cellated structure between the trochanter major and trochanter
minor, where it had been united with the cancelli. But the
most curious circumstance in this dissection was, that in order
to give the support which the body required for a limb in such
a state, an addition had been made both to the trochanter major
and the trochanter minor, by which means they rested against
the edge of the acetabulum, and in every slight change of
position, would give an opportunity for the weight of the body
to be supported by these processes resting on the os innominatum.
{See plate.)
James Powell.
My friend, Mr. Roux, sent me from Paris a fractured thigh-
bone, in which the neck of the bone had been broken at the
same part as in Mr. Powell's case, and had been united in a
similar manner. But it frequently happens in this injury, that
the fracture of the neck of the thigh-bone is complicated with
an injury of the trochanter major and trochanter minor.
150 FRACTURES OF THE UPPER PART
CASE II.
Mr. Wray, surgeon, in Fleet Street, was so kind as to present
me with a fracture of this description, and the following are the
particulars of the case : —
A man, aged sixty-four, was standing by his bed-side, when
he suddenly fell to the ground, as it was supposed in a fit, and
on the attempt to raise him, he was found unable to stand.
Mr. Wray was called to him, and he found his right leg some-
what shorter than the other, and the limb everted. Motion of
the limb gave him excessive pain ; no crepitus could be perceived
in the examination which he would permit Mr. Wray to make.
The limb was placed in a straight position, and a. constitutional
treatment was pursued, but a high degree of irritative fever
succeeded, and on the fourth day from the accident the man died.
Upon examination of the body, great extravasation of blood was
found both externally to the muscles and between them ; sup-
puration had commenced near the trochanter major, and a
fracture was found at the neck of the thigh-bone and into the
trochanter, by which the neck had been received into the can-
cellated structure of the shaft of the bone.
Mr. Travers has a most valuable specimen of this fracture,
which occurred in a patient of his at St. Thomas's Hospital,
and of which he has had the kindness to give me the following
account.
CASE III.
Richard Norton, aged sixty, fell upon the curb-stone of the
foot-pavement, and struck the upper and outer part of his left
OF THE THIGH-BONE. 151
thigh with great violence. He was admitted into St. Thomas's
Hospital, on the 24th of January, 1818. The tension was then
considerable ; the line of the tensor vag'inae femoris formed an
arch ; the limb was shortened ; the foot inclined outwards ; the
motion of the limb was free in all directions ; but it was painful,
more especially when the knee was carried over the opposite
thigh. The crepitus of the trochanter major was distinctly felt
in these motions, and the swelling of the parts, with the extensive
crepitus, gave an idea that the accident was a comminuted state
of the trochanter, and that the base of the cervix femoris was
broken ; hence the shortening of the leg, and the eversion of the
foot. After the use of evaporating lotions for some days, the
tension subsided, so as to allow the application of the long outer
splint and two thigh -splints well bedded. On March the 4th,
the splints were removed, and union appeared to have taken
place, for the limb had resumed its natural figure, but was a
little shorter than the other. In the course of a month more he
began to use his crutches. On April the 15th, he was placed
under the physician for defect in his general health ; and when
he was upon the point of quitting the hospital, he was seized
with spasms in his chest, of which he suddenly expired.
Upon examination, some old adhesions of the pleura, and water
in the chest, and pericardium, were found. The fracture was
through the trochanter, as had been supposed, extending some
way down the bone, and it apparently had united, with very
slight deformity; but on maceration, the head and neck of the
bone became loose in the thigh-bone, and a fracture was found
152 FRACTURES OF THE UPPER PART
there, which locked the head and cervix in a shell of bone formed
around them.
B. Travers.
Mr. Travers having sent me the bone, the following are the
appearances of this curious case. The head and cervix had been
separated from the trochanter major and body of the bone. The
upper part of the thigh-bone was obliquely split, so as to receive
the cervix femoris into the cancelli. This fracture of the thigh-
bone separated the posterior portion of the trochanter major from
the body of the thigh-bone, and the trochanter minor was removed
with it. An union had taken place between the fractured portions
of the trochanter, at a slight distance from each other, and thus a
hollow was left, into which the cervix femoris was received, and
it had not yet become united by ossific deposit, as the man had not
lived sufficiently long for firm consolidation under his reduced state ;
for upon maceration, the neck of the bone had free play in the
cavity in which it had been received, and from which it could not
be removed.
Mr. Oldnow, of Nottingham, who is a very intelligent surgeon,
sent me two very excellent specimens of this fracture, in which
the necks of the bones were broken at their junction with the
trochanter major. The trochanter major itself had been also
broken off, and the trochanter minor formed a distinct fracture.
The bones had become re-united ; the cervix femoris to the shaft
of the bone, and the trochanter minor a little higher than its
natural attachment. The trochanter major was in one specimen
re-united to the body of the bone, but not in the other. Thus
OF THE THIGH-BONE. 153
\
the thigh-bone was at its upper part divided into four portions ;
the head and neck of the bone formed one portion ; the trochanter
major a second ; the trochanter minor a third ; and the body of
the bone the fourth. The union was accompanied by very little
shortening' of the thigh. (^See plate.)
Since the publication of the former edition of this work, I have
inspected, with Mr. Key, a fracture of the neck of the thigh-bone.
The moment I had examined the patient, I pronounced the case
to be a fracture external to the capsule, and was led to believe
so from some little diminution in the length of the limb ; from
the ecchymosis which attended it ; from its distinct crepitus
without any rotation ; from the diminished motion of the upper
part of the thigh ; from the sunken state of the trochanter ; and
from excitement of great pain by the smallest motion. This
man died in a fortnight after the accident.
When the body was placed upon the table for examination, post
mortem, all the limbs were rigid from the fixed contraction of the
muscles, and, consequently, the thigh was drawn up to its greatest
possible extent ; yet the limb was found to be not quite three
quarters of an inch shorter than the other. The posterior part
of the sheath of the vessels, and some branches of blood-vessels,
were torn by the bone, which accounted for the ecchymosis. The
neck of the bone was forced into the cancelli of the trochanter
major.
Before writing this statement, I again inquired of Mr. Key, the
degree of diminution in the length of the limb, and his answer
was, "If you mention three quarters of an inch, you will state
rather more than its degree of retraction, even when all the
X
154 FRACTURES OF THE UPPER PART
muscles were contracted to their utmost rigidity." I shall be
happy to shew the parts which I removed from the case, with all
the surrounding muscles, to any person who wishes to see them,
as they at once explain the nature of the accident, and the reason
why the limb is so little shortened.
Although, then, this accident has some of the marks of fracture
of the neck of the bone within the ligament, yet it unites by bone,
and it will be seen that the union is similar to that of other bones
external to the joints; cartilage is first deposited, and then the
matter of bone, because in this case the parts can be brought into
apposition, and the ends of the bones are confined together by
the surrounding muscles ; one portion is pressed against the other,
and the neck of the bone sinks deeply into the cancellated struc-
ture of the trochanter ; thus direct approximation and pressure
are preserved when the fracture is at the junction of the cervix
with the trochanter, and the nutrition of each extremity of the
bone is well supported by the vessels which proceed to it from
the surrounding parts.
Diflferenceof "VV^e uow scc the rcBSon of the difference of opinion respecting*
opinion re- A i o
conciied. ^Y\e union of fracture of the neck of the thigh-bone. In the
internal fracture the bones are not applied to each other, and the
nutrition of the head of the bone being imperfect, in general no
ossific change is produced ; but in the external fracture the bones
are held together by the surrounding parts, easily kept in appo-
sition by external pressure, and there is not only ossific union,
but very exuberant callus. Much time is required in these
accidents to produce a complete ossific union ; and the neck of
the bone, received into the cancelli, moves for a long period in
OF THE THIGH-BONE. 155
its new situation; although it is so far locked in as to prevent
its separation.
In the treatment of this injury, the principle is to keep the Treatment.
bones in approximation by pressing the trochanter towards the
acetabulum ; and the length of the limb is preserved by applying
a roller around the foot of the injured leg, and by binding the
feet and the ancles firmly together, so as to prevent their retrac-
tion, and thus cause the uninjured side to serve as the splint to
that which is fractured, giving it a continued support. A broad
leathern strap should also be buckled around the pelvis, including
the trochanter major, to press the fractured portions of the bone
firmly together, and the best position for the limb is, to keep it
in a straight line with the body.
The following plan I have also known successful : — The patient
being placed on a mattress on his back, the thigh is to be brought
over a double inclined plane composed of three boards, one below,
which is to reach from the tuberosity of the ischium to the
patient's heel, and the two others having a joint in the middle by
which the knee may be raised or depressed ; a few holes should
be made in the boai*d, admitting- a peg, which prevents any
change in the elevation of the limb but that which the surgeon
directs ; over these a pillow must be thrown, to place the patient
in as easy a position as possible.* (See plate.)
When the limb has been thus extended, a long splint is placed
upon the outer side of the thigh to reach above the trochanter
* The construction of this inclined plane is so little complicated, that it may be made at the
instant of two common boards, one of which is to be sawn through nearly at the middle, and if
hinges cannot be immediately procured, the boards may be nailed together thus
X 2
156 FRACTURES OF THE UPPER PART
major, and to the upper part of this is fixed a strong leathern
strap, which huckles around the pelvis, so as to press one portion
of bone upon the other ; and the lower part of the splint is fixed
with a strap around the knee to prevent its position from being-
altered; the limb must be kept as steady as possible for many
weeks, and the patient may be permitted to rise from his bed when
the attempt does not give him much pain ; he is still to retain the
strap which I have mentioned round the pelvis ; and by this
treatment he will ultimately recover with an useful, though
Recovery, shortcncd limb.
FRACTURES THROUGH THE TROCHANTER MAJOR.
Oblique fractures sometimes happen through the trochanter
major, and the cervix ossis femoris does not participate in the
injury. This accident occurs at every period of life, and its
symptoms are as follows : — the leg is very little, and sometimes
not at all, shorter than the other, and the foot is benumbed; in
some cases the patient is unable to turn in bed without assistance,
and the attempt gives him great pain. The broken portion of the
trochanter major is, in some cases, drawn forward towards the
ilium ; in others, it falls towards the tuberosity of the ischium ; but
is, in general, widely separated from that portion which remains
connected with the neck of the bone. The foot is greatly everted ;
the patient cannot sit, and any attempt to do so produces excessive
pain. Crepitus is with difficulty discovered if the trochanter is
either much fallen, or much drawn forwards.
OF THE THIGH-BONE. 157
The distinguishing' marks of this accident are, a fixed state of
the upper part of the trochanter, whilst its lower part obeys the
motion of the thigh-bone ; eversion of the foot, and the very-
perceptible altered position of the trochanter major ; attended
with crepitus under very extended motion of the upper part of
the limb, and with little diminution of its length.
But when the fracture happens below the insertion of the
principal rotatory muscles, the lower portion of bone is much
raised by the action of the gluteus maximus, and the limb
becomes very much shortened and deformed at the place of union
by exuberant callus.
This fracture unites very firmly, and more quickly than when
the cervix is broken at the root of the trochanter, and the patient
recovers with a very good use of the limb.
The first case of this kind I ever saw was in St. Thomas's
Hospital, about the year 1786. It was supposed to be a fracture
of the neck of the thigh-bone within the capsule, and the limb was
extended over a pillow rolled under the knee, with splints on each
side of the limb, by Mr. Cline's direction. An ossific union
succeeded, with scarcely any deformity, excepting that the foot
was somewhat everted, and the man walked extremely well.
When he was to be discharged from the hospital, a fever attacked
him, of which he died; and upon dissection, the fracture was
found through the trochanter major, and the bone was united
with very little deformity, so that his limb would have been
equally useful as before.
The following case I attended with Mr. Harris, surgeon, at
158 FRACTURES OF THE UPPER PART
Reading, who has been so kind as to communicate the circum-
stances in detail.
CASE.
On Friday, July 20th, 1821, I was sent for to Mr. B , a
gentleman, living about six miles from Reading, who, I under-
stood from the servant, had met with an accident, and put out
his hip. I found him placed on a board in his bed-room, and
on inquiry learnt that his horse had fallen with him when putting
him into a trot, and he was thrown, and fell on his left hip on
the road. He immediately got on his legs, and walked a few
steps, but soon found an inability to bring his left leg forward,
and complained of pain in his left hip. He was placed in a cart,
and supporting his left leg by taking the stirrup and placing his
foot in it, holding it steady by the leather, he was conveyed home,
a distance of about four miles. I reached him within two hours
of the accident, and on examining the limb, I immediately per-
ceived that there was not a dislocation.
I could not discover any crepitus in rotating the limb ; it was
of the same length as the other, and neither turned inwards or
outwards ; and he had the power of retaining it in any position in
which you chose to place it. The integuments in the neighbour-
hood of the trochanter major were a good deal swollen; and he
complained of pain, but could bear the limb moved in any
direction, without much, or, indeed, any inconvenience, except
when drawn across the other, and then great pain was felt in
the situation of the trochanter minor. I then gave it as my
opinion, that there was neither dislocation nor fracture, and I
thought he would be well in a few days. I directed some leeches
OF THE THIGH-BONE. 159
to be applied over the trochanter major, and an evaporating
lotion, and took about twelve ounces of blood from the arm ;
and as he was in the habit of taking the pil: hydrarg: I directed
him to take a pill at bed-time, and some Cheltenham salts in
the morning.
I should observe, that in making my examination, I discovered
that Mr. B had formerly experienced a fracture of the patella
of the right knee, which had united by a ligament of near two
inches in length; and on inquiry I learnt, that it had been
fractured three times — in 1795, 1796, and 1800. He is of tall
stature, and rather thin; and at the time of the present accident
was in the fifty-first year of his age.
On seeing Mr. B the next day, the 21st, I found he had
had no sleep, and was totally unable to move the limb without
assistance; his medicine had operated. On the 22nd there was
no improvement in the powers of the limb ; the part was still
much swollen, although the leeches had drawn a considerable
quantity of blood. As there was a disposition to inflammation
from the bite of the leeches, I ordered a poultice of linseed meal
and bread crumbs, which removed it in a day or two. Mr. B
informed me, that Mr. Ring, of Reading, had called on him, and
had examined the limb very minutely, and measured it and found
it to correspond in length with the other ; and then told him
that he was happy to confirm Mr. Harris's opinion of the case.
On the 26th, Mr. B was attacked with an acute hepatitis,
which very nearly proved fatal. From that time to the 28th, he
was bled four times from the arm, to the extent of ninety-six
ounces of blood, and took a saline purgative draught and calomel;
]60 FRACTURES OF THE UPPER PART
during this period the limb remained in much the same state.
Dr. Taylor saw him about this time. The limb was moved daily,
and I began to think it did not improve so much as it ought ;
as it appeared at first to be only a simple contusion, and the
antiphlogistic treatment pursued for the cure of the hepatitis
should also, we thought, have benefited the limb.
On August the 14th, whilst Mr. Ring was moving the leg, he
thought he felt a crepitus, which he communicated to me, and I
remarked that it was impossible. I did not move the limb on
that day, but on the following I rotated it, and distinctly felt and
heard the crepitus. Mr. B also heard it, and said, " Why,
you do not mean to find a fracture now ?" I expressed my fears
that there was a fracture, but could not say where, but thought it
was through the cervix of the femur ; although every symptom,
saving the crepitus, was wanting to such an accident. I commu-
nicated my opinion to Mrs. B , and it was immediately
arranged for Mr. Brodie to be sent for, who came the following
day at noon (the 18th), and met Dr. Taylor, Mr. Ring, and
myself. The particulars of the case were communicated to him,
and he proceeded to examine the limb, moving it in every direC"
tion ; but could not then discover a crepitus, or any symptom
denoting a fracture, as the limb was still of the same length with
the other, and neither turned inAvards or outwards. Mr. Brodie
was in the first instance doubtful as to there being a fracture.
We told him that we both (that is, Mr. Ring and myself), had
distinctly felt the crepitus, and that it was not discoverable but on
certain motions of the limb. Mr. Brodie then examined the limb
with the greatest attention, and in rotating it very extensively he
I
OP THE THIGH-BONE. 16*1
felt the crepitus. Yet when the patient was standing- upright
out of bed, supported, and with the right leg elevated from the
ground, he bore very considerably on the injured limb, so much
so as to produce from Mr. Brodie an exclamation of surprise ;
and he gave it as his opinion, that such was the obscurity of
the case, that had he seen it a week before, he should decidedly
have said that there was not a fracture, as in fact every symptom
at that time was completely wanting, except the inabilitv to
move the limb; but now he believed a fracture existed in the
cervix femoris, or in the superior part of the thigh-bone, where
the cervix joins it.
The treatment recommended by Mr. Brodie was, a long splint
placed on the outside of the limb, and a bandage from the toes to
the hip, which he applied himself, and he ordered it to be worn
for one month, and that the limb should be kept entirely free from
motion.
At the expiration of a month Sir A. Cooper was sent for, who
arrived at E on September the 11th. After the accident had
been stated to him, he proceeded to examine the limb ; he first
observed the relative position of the two limbs (Mr. B still
lying on his back, with the limb resting on the heel), and then
passing his hand under the trochanter major, he raised it easily, it
having now dropped from its natural position ; and he agreed with
Mr. Brodie and ourselves in declaring the fractui'e to be placed in
the trochanter major, where it unites with the cervix femoris.
The treatment Sir A. Cooper recommended was, to keep the
trochanter in its proper position ; the patient to remain in the
horizontal posture ; and the most perfect quiet to be observed.
Y
162 FRACTURES OF THE UPPER PART
The plan adopted to accomplish these objects were the fol-
lowing :
A mattress was made of horse-hair about five inches thick, and
very smooth, and this was covered with a sheet. A part of the
mattress was made to draw out on the opposite side to the frac-
ture, so that when the necessary evacuations took place, there still
should be no motion of the body. Before drawing out the piece
of mattress, a board of two feet long, and six inches wide, shaped
like a wedge, was insinuated under the buttock of the right side,
the two ends of the board resting on the mattress ; thereby pre-
venting the nates from sinking at all into the opening when the
piece of mattress was removed, and the injured side still rested on
the body of the mattress : the board was of course removed after
the mattress was replaced. Upon the bedstead was first placed a
thick smooth board, sufficiently large to cover the bottom of the
bed, and on that was placed the mattress, thereby preventing any
sinking by the weight of the body.
The bandage recommended by Sir A. C. was the following : a
broad web, sufficient to go round the body over the hips, was fixed
with two buckles and straps, and a piece was added to make it
wider where it passed under the injured trochanter ; this was lined
with chamoise leather, and stuffed : a pad of the same leather,
which was about six inches long, three broad, and three inches
thick, and ending gradually in a point, was placed immediately
under the trochanter major of the injured side, so that when the
bandage was buckled, the pad passed into the hollow beneath the
trochanter, and when the bandage was tightened, it forced the
trochanter upwards and forwards into its natural position: then
OF THE THIGH-BONE. 163
another pad was made very thick, about eight inches square, in
the shape of a wedge, and this was placed under the upper part
of the thigh, after the bandage was fixed on. The patient was
placed on his back, the limb resting on the heel ; and to prevent
the possibility of any motion of the foot and of the body, a wide
board was fixed to the bed-posts at the foot of the bed, with two
pieces of wood padded and fastened to it, into which the foot was
received, and the least lateral motion prevented. A cushion was
placed opposite the other foot, so that pressure could be made
against the board, thereby preventing the body from slipping
down in the bed.
Sir A. C. gave directions that Mr. B should not quit the
horizontal posture ; and ordered him occasional purges, and a
generous diet. This treatment was adopted on September the
13th, and he passed a tolerable night, and did not complain of the
bandage. Nothing particular occurred during the month, except
that the patient suffered occasionally from bilious head ache and
vomiting, which were removed by purging. The bandage was
tightened every now and then, but not to any great degree till
the expiration of three weeks, when Mr. B told me he was
certain that he still felt the crepitus, when I urged the absolute
necessity there was of tightening the bandage, and thus, by pres-
sure, to produce a degree of inflammatory action in the bone.
I should judge that when Sir A. C. saw Mr. B , the ends
of the bone were as much as two inches apart, but that was most
certainly not the case when Mr. Brodie examined the limb ; the
separation had taken place during the last month.
From this time the bandage was kept as tight as it could
Y 2
164 FRACTURES OF THE UPPER PART
jDOSsibly be borne (and it never shifted in the least from the posi-
tion in which it was first placed), and no feeling of crepitus was
afterwards complained of. The swelling of the thigh and leg was
much increased, as if distended with coagulable lymph ; it pitted
on pressure, but it required some degree of force to produce that
effect. Pain was still complained of in the direction of the tro-
chanter minor; the bowels were torpid, and required opening
medicines every other day.
Sir A. C. visited Mr. B a second time, October 16th; the
bandage was not removed, nor was the position changed. He
gave it as his opinion that union had begun, and directed the
patient to continue in the same position, which he did, without any
thing material occurring except bilious attacks, till December the
30th, when Sir A. C. visited him a fourth time : he had seen him
in the interval between October the 16th and December the 30th,
but nothing particular had occurred.
December the 30th, Sir A. C. removed the bandages for two
hours ; the bone remained in its natural position ; and on exami-
nation we could feel a great thickening of the parts about the
trochanter. He ordered him to stand at the side of the bed after
the bandage had been removed, and he stood with support a few
minutes, when he became faint, and was removed to his bed. Sir
A. C. wished the bandage to be replaced ; but to be re-applied
once a day for an hour, and the limb to be rubbed from the foot
upwards. The thigh became much softer during the two hours in
which the bandage was removed ; the boards which supported the
foot were now also removed, as well as the bandages, and Mr.
B was placed on crutches. From this time he rose every
OF THE THIGH-BONE. 165
day ; and the limb continuing very much swollen, it was rubbed
daily from two to four hours ; still he could not bend the knee ;
but when standing on his crutches he had a most perfect use of
the hip-joint. We endeavoured to regain the motion of the
knee by friction with oily embrocations. On Friday, March 1st,
Mr. B left E in his carriage for London.
Samuel Harris.
Since his arrival in London, Mr. B has, with great steadi-
ness, employed friction and passive motion for the recovery of the
use of the knee with the happiest effect, and the hip-joint is
entirely restored to its natural powers.
A. C.
CASE.
]Mr. Peggler, of Wanstead, aged forty-six, on the 13th of
November, 181 7* fell, while walking, on a glass bottle which he
had in his pocket ; and when he attempted to raise himself from
the ground he found he was not able to stand. In a quarter of an
hour he felt great pain, and could not bear the slightest weight of
his body on the injured limb. Mr. Constable, of Woodford, was
sent for, and he gave me the following account of the case. The
foot, at first, did not appear to turn out^ but when the patient
was put into bed, and laid on his back, it became everted : the
leg appeared somewhat shorter, but was with little difficulty
pulled down to its natural length : the foot was benumbed, and
continued so for twelve months. He was placed in bed, with a
bolster under the hip to prevent displacement of the bone; and
his knees and ancles were tied together.
166 FRACTURES OF THE UPPER PART
In December following, about Christmas, I met Mr. Constable,
whilst visiting a patient with a severe injury of the head, and he
then requested me to see Mr. Peggler, whom I found incapable of
turning in his bed without assistance, and the attempt gave him
great pain ; his injured leg was a little shorter than the other, and
the trochanter was drawn forward towards the spine of the ilium,
and could be felt considerably separated from that portion of the
trochanter connected with the neck of the bone ; the foot was
turned outwards ; he could not sit, and the least attempt to raise
himself produced excruciating suffering. I brought him to the
foot of the bed in an horizontal position, to make as accurate an
examination as I could of the nature of the accident, and had no
hesitation in pronouncing it a fracture through the trochanter.
In less than a month he began to use his crutches, and continued
their use for three months ; he then laid aside one crutch, and
employed a stick and crutch, and in a short time needed the sup-
port of a stick only ; but it was twelve months before he recovered
the entire use of his limb. The leg is still nearly an inch shorter
than the other ; the portion of the trochanter connected with the
thigh-bone has united with the fore part of the trochanter joined
to the neck of bone, and is, consequently, much nearer the
spine of the ilium than usual ; the foot is also slightly everted,
but he walks extremely well ; a week ago he walked ten miles
from home, and returned the same day ; and this day, July 28th,
1819, he has walked from Wanstead to my house, and intends to
walk back, a distance of near twenty miles.
This history of Mr. Peggler's accident is so similar to the cases
OF THE THIGH-BONE. 167
of fracture through the trochanter major which I have had an
opportunity of seeing, that a detail of the latter would only-
become an useless repetition; the only variations that I have wit-
nessed having' been in the distinctness of the crepitus accompa-
nying them, which is less in proportion as the fracture approaches
the capsular ligament. I have lately fractured through the tro-
chanter major, five different thigh-bones in the living animal ;
they united, but with great distention, shortening, and exuberant
callus.
To conclude. — As diminution of the length of the limb, and its
eversion of the knee and foot, are signs which are common to
fractures of the thigh-bone generally, it may be proper, before
quitting the subject, to bring into one view the means of dis-
tinguishing the three species of fracture which I have described.
The fracture of the cervix tvithin the capsule is known, with
very rare exceptions, by the very advanced age of the patient, —
by its greater frequency in female than in male subjects, — by the
absence of swelling and ecchymosis, — by the elevation and advance
of the trochanter, — by the greater mobility of the joint, allowing
flexion and extension, although with some pain, and resistance
from muscles, — by a crepitus perceptible only on drawing
down the limb to the same length with the other, and then
rotating it, — by the pain felt at the trochanter minor, — by little
constitutional irritation attending the accident, — by the slight
causes which produce it, — and by the little local swelling or
change of appearance which ensues.
Fractures of the cervix into the cancelli of the trochanter are
known by the effusion of blood amidst the muscles, — by great
168 FRACTURES OF THE UPPER PART
swelling' produced, and by ecchymosis, which appears soon after
the accident, — by an unnaturally fixed state of the joint, so that
flexion and extension cannot be performed, — by excessive pain
being" produced on the least motion of the hip-joint, and upper
part of the thigh-bone, — by a crepitus being perceived under the
least motion of the thigh-bone, without drawing it down to the
length of the other, — and by the inflammation, swelling, and
constitutional irritation produced, which are frequently destructive.
The fracture of the trochanter major may be easily known by
the separation of the bone at the part, so that the finger may be
placed between the fractured portions, — by the distinct crepitus
felt in putting the fingers on the trochanter when the knee is
advanced, — by the upper portion of the trochanter not obeying
the motions of the lower, and of the shaft of the bone, — and when
at the lower part of the trochanter, by great overlapping, dis-
tention, and exuberant callus.
I have thus stated what dissection and observation have taught
me of the three fractures of the upper part of the thigh-bone,
and shewn it to be a general principle, that fractures within the
capsule do not unite by bone. I ought to add, that, in the
Museum of Mr. Langstaff, there is a preparation of fracture
within, and of one external to the ligament ; the latter firmly
united by bone, whilst the former has scarcely undergone any
ossific change. I can have no wish but that these fractures within
the capsule should unite by bone, if that result be desirable.
I only state what dissection has taught me; and, with respect
to contrivances to produce their union, I cannot extol them until
there be some evidence of their value.
OF THE THIGH-BONE. ] 69
FRACTURE OF THE EPIPHYSIS OF THE
TROCHANTER MAJOR.
Mr. C. Aston Key, Surgeon to Guy's Hospital, has had the
kindness to send me the following account of a peculiar fracture
of the trochanter major, in which this process was broken from
the thigh-bone at the part at which it is naturally united by
cartilage as an epiphysis in youth.
CASE.
The subject of the accident was a young girl about the age of
sixteen, who, in crossing the street with a can in her hand,
tripped, and in falling, struck her trochanter violently against
the curb stone. She immediately rose, and without much pain
or difficulty walked home. The accident occurred on Saturday,
March 15th, 1822; and, in consequence of the increase of pain
she experienced on the inner side of the thigh, she presented
herself at Guy's for admission on the Thursday following. Her
constitutional symptoms being evidently more violent than those
which usually arise from fractured femur, she was placed under
the care of the physician, Dr. Bright, at whose request I
examined the limb. Her right leg, which was the one injured,
was considerably everted, and appeared to be about half an inch
longer than the sound limb. It admitted of passive motion in all
directions, but in abduction gave her considerable pain. She had
perfect command over all the muscles except the rotators inwards.
The fact that she had walked both before and since her admission
170 FRACTURES OF THE UPPER PART
into the hospital, gave rise to some doubts as to the existence of a
fracture, and the closest examination of the trochanter and body
of the femur could not detect the slightest crepitus or displace-
ment of bone. I repeated the examination of the limb on the
following day, but the result was equally unsatisfactory.
The fever under which she was labouring, together with general
abdominal uneasiness, threatening her life, the limb underwent no
further examination. She died on Monday, nine days after the
accident.
Examination after death.
Wishing to ascertain (for I suspected some obscure fracture
of the OS femoris) the exact nature of the injury, previously to
removing the soft parts I moved the limb in every direction, fix-
ing the trochanter and head of the bone ; but I could perceive no
deviation from the usual state of parts, nor could I distinguish the
slightest crepitus under all the variety of movements. I should
observe, that there was no tumefaction of the thigh, and therefore
the trochanter and head of the os femoris were as readily distin-
guished and exposed to examination as in the most healthy limb.
The capsule of the joint being laid bare, a cavity was discovered
by the side of the pectineus, leading backwards and downwards,
towards the trochanter minor, and containing some pus : it
allowed the fingers to pass behind the bone to the greater tro-
chanter. The head of the bone was then dislocated by cutting
through the ligaments, and not till then was a fracture discovered
at the root of the trochanter major. The upper half of the femur
being removed from the body, I discovered the reason why the
fracture had eluded our search.
OF THE THIGH-BONE. l/l
The fracture had detached the trochanter from the hody and
neck of the bone, but without tearing through the tendons
attached to the outer side of the process. The tendons are those
of the two smaller glutaei, and the commencement of that of the
vastus externus ; had they been torn, the broken portion of bone
would have been drawn upwards by the action of the two former
muscles, and, in that case, the injury would readily have been
recognized ; but they so effectually prevented all motion of the
fractured portion that, when dissected from the body, not the least
motion could be produced except in one direction. It was found
that this motion resembled that which would be produced by a
hinge ; the tendons acting the part of a broad hinge, and allowing
the portion to be moved only upwards and downwards. It is
evident that such motion could not have been produced by any
direction given to the limb ; hence it is also manifest that the
fracture could not have been detected during the life of the
patient. C. A. Key.
FRACTURES BELOW THE TROCHANTER.
The thigh-bone is sometimes broken just below the trochanter
major and minor; it is a difficult accident to manage, and
miserable distortion is the consequence if it be ill treated. The
end of the broken bone is drawn forwards and upwards, so as
to form nearly a right angle with the body, and the cause of
this position is evidently the contraction of the iliacus internus
z2
17*2 FRACTURES OF THE UPPER PART
and psoas muscles, assisted by the pectinalis, and perhaps by the
first head of the triceps. A better idea of the effect of this
accident may be obtained by a view of the plate, in which the
bone will be observed to be united, not only with extreme
shortening, but with a hideous projection forwards. If pressure
be made upon the projecting bone in the treatment of this case,
it only adds to the patient's suffering, and to the degree of
irritation of the limb, without preserving the bone in its proper
situation. It will be seen that this union exceedingly overlaps,
and that it is very feeble ; shewing, what I have already men-
tioned, that a fracture thus circumstanced has the ossific depo-
sition only on that side where the inflammation was preserved by
the pressure of one bone on the other. This preparation may be
seen in the Anatomical Museum, St. Thomas's Hospital. (See
plate.)
To prevent this horrid distortion and imperfect union, two
circumstances are to be strictly observed : the one is, to elevate
the knee very much over the double inclined plane ; and, the
other, to place the patient in a sitting position, supporting him by
pillows during the process of union. The degree of elevation of
the body which is required will be about forty-five degrees, but it
may be readily ascertained by observing the approximation of
the fractured extremities of the bones ; and this position is
demanded to relax the psoas and iliacus muscles, and thus
prevent the elevation of the upper part of the bone. In this
manner, and thus only, can the great deformity I have described
be prevented. When, by this posture, the extremities of the
OF THE THIGH-BONE. 1/3
bones are brought into proper apposition, and all projection of
its upper portion is removed, either the splints may be applied
which are commonly used in fracture of the thigh-bone, or, what
is better, a strong leathern belt, lined with some soft material,
should, by means of several straps, be buckled around the limb,
and be confined by means of a strap around the pelvis.
DISLOCATIONS OF THE KNEE.
The broad surfaces of bone by which the os femoris rests upon
the tibia are calculated to prevent the ready dislocation of this
joint, which would be otherwise very liable to happen from the
superficial nature of the articulating cavities on the head of the
tibia, and also from the great violence to which this joint is
frequently exposed.
structure Thc dcprcssious upon the head of the tibia are increased by the
of the knee. ,,.. n i •! •! ^ • t
addition oi the semi-lunar cartilages which rest upon the bone;
they receive the condyles of the os femoris, and are attached
by ligaments to the edge of the tibia. The fore part of the joint
g^jjg is defended by the patella, which has two unequal articular
surfaces to play upon the condyles of the os femoris. The head
of the fibula forms no part of the knee-joint, but is attached to
the tibia from one half to three-fourths of an inch below its
head.
The junction of the os femoris, tibia, and patella, is produced
Ligaments, by mcaus of 'd capsular ligament, which proceeds from the os
DISLOCATIONS OF THE KNEE. 175
femoris to the head of the tibia, and is attached to the edge of
the patella, Avhere it divides into two portions, forms wings to that
bone, and takes the name of the alar ligament. On its outer side
the capsular ligament is covered, and greatly strengthened, by
tendinous expansions, which are derived from the vasti muscles,
and which proceed to the head of the tibia. Internally the liga-
ment has a secreting synovial surface, which is folded within the
cavities at the extremities of the bones, and is reflected to the
edge of the articular cartilages, and, it is believed, forms a cover-
ing to those cartilages. Beside the capsular, there are several
peculiar ligaments. First: The ligamentum patellae, which is
extended from the lower point of the patella to the tubercle of the
tibia. Secondly : The external lateral or femoro-fibular ligament,
which passes from the os femoris to the head of the fibula, and
which divides into two external lateral ligaments. Thirdly : The
internal lateral or femoro-tibial ligament, being attached to the
OS fomoris and to the head of the tibia. Fourthly : The oblique
or popliteal ligament, which proceeds from the external condyle of
the OS femoris obliquely, to be inserted into the head of the tibia.
Fifthly : The crucial ligaments, which pass from the depression
between the condyles of the os femoris bel^nd ; the one to a pro-
jection between the articular surfaces of the head of the tibia, and
the other to a depression behind that projection, so that these
ligaments cross each other from before backwards. The patella
has a muscular connection with the os femoris by the insertion of
the rectus, vasti, and cruralis. By the ligamentum patellae it is
united with the tibia, and laterally it is joined to the capsular and
176 DISLOCATIONS OF THE KNEE.
alar ligaments. This ligamentous junction of the three bones is
very firm, but it allows of free flexion and extension., with some
degree of rotatory motion when the knee is bent ; but although
great strength is evident in the construction of this joint, still
excessive violence and extreme relaxation will occasionally pro-
duce its dislocation.
DISLOCATION OF THE PATELLA.
Three Thc patella is liable to be dislocated in three directions, namely:
outwards, inwards, and upwards. In its lateral dislocation, the
bone is most frequently thrown on the external condyle of the
Symptoms. OS fcmoHs, whcrc it produces a great projection ; and this circum-
stance, with an incapacity of bending the knee, is the strong
Cause. evidence of the nature of the injury. The most frequent cause of
the accident is, that a person in walking or running, falls with his
knee turned inwards, and the foot outwards ; and thus, by the
action of the muscles to prevent the fall, the patella is drawn over
External, tlic cxtcmal condylc of the os femoris ; and when the person
attempts to rise he finds himself unable to bend his leg, and the
muscles and ligaments of the patella are all forcibly on the
stretch. This accident generally occurs in those who have some
inclination of the knee inwards, which, under the action of the
extensor muscles, gives a direction to the patella outwards.
Internal. The internal dislocation is much less frequent, and it happens
from falls upon a projecting body, by which the patella is struck
DISLOCATIONS OF THE KNEE. 177
upon its outer side, or by the foot being, at the time of the fall,
turned inwards. In either of these cases the ligament will be
torn, unless there be some previous disease.
Mr. Harris, getting into a chaise, caught his foot in the carpet
at the bottom of it, by which accident the knee was turned in
and the leg outwards ; the patella slipped upon the external
condyle of the os femoris, but it returned very soon, by the
effort of the muscles, into its natural situation. On examination,
I found the internal portion of the capsular ligament torn, and
a great accumulation of synovia in the joint.
The mode of reduction in either case consists in pursuing Mode of
1 p n • 1 nrn • • i i • i reduction,
the loUowing plan: Ihe patient is placed in a recumbent pos-
ture, and an assistant raises the leg by lifting it at the heel;
the advantage of which is, that it relaxes the extensor muscles
on the thigh in the greatest possible degree ; the surgeon then
presses down that edge of the patella which is most remote from
the joint, be it one luxation or the other ; and this pressure
raises the inner edge of the bone over the condyle of the os
femoris, and it is immediately drawn, by the action of the mus-^
cles, into its natural situation.
My friend, Mr. George Young, informed me, that he was
called to a case of dislocation of the patella outwards, in which
the reduction was very difficult. The patient was a female, who,
by a fall in walking, had the patella drawn over the external
condyle of the os femoris, where it remained. He employed
pressure upon the edge of the patella, most perseveringly,
without being able to succeed, but at last reduced it in the
A A
178 DISLOCATIONS OF THE KNEE.
following' manner : — he placed the patient's ancle upon his
shoulder, and thus most completely extended the limb and
obtained a fixed point of resistance at the knee ; then grasping
the patella with the fingers of his right hand, he pressed the
outer edge of the patella with the ball of his left thumb, and
pushed it into its place.
When the reduction of this bone has been effected, an
evaporating lotion of spirits of wine and water is to be applied ;
in two or three days the limb may be bandaged, and it is soon
restored to its natural uses, although it is somewhat weaker
than before.
I was informed by Mr. Welling, formerly surgeon at Hastings,
that he was called to a case in which the patella was dislocated
upon its edge. The nature of tbe accident was very obvious,
as the edge of the bone forced up the integuments to a consider-
able height between the condyles on the fore part of the joint.
Mr. Welling reduced the dislocation, but with considerable
difficulty, by pressing the edges of the bone in opposite directions.
Dislocation Wlicn thc bouc is dislocated from relaxation, the patella is
from relax-
drawn upon the external condyle of the os femoris by very slight
accidents, or sudden action of the muscles. My neighbour,
Mr. Hutchinson, a very intelligent surgeon, informs me he has
very frequently seen this accident, and that the tendency to it
has arisen, in a larg'e proportion of cases, from the relaxation
produced by excessive indulgence in onanism.
The reduction, in these cases, is effected in the manner which
has been before described; and after the reduction, to prevent
atioD.
DISLOCATIONS OF THE KNEE. 1/9
any recurrence of the accident, and to support the weakened
ligament, a laced knee-cap, with a strap and buckle above and
below the patella, is to be worn.
I once saw the patella drawn over the external condyle of the
OS femoris from loss of action of the vastus internus, owing to a
disease in the thigh-bone.
DISLOCATION OF THE PATELLA UPWARDS.
In this dislocation, the ligament of the patella is torn through upwards.
by the action of the rectus femoris muscle, and the immediate Ligament
lacerated,
effect of the injury is, to draw the patella upwards upon the
fore part of the thigh-bone. The appearances which this acci- symptoms,
dent presents are very decisive of the nature of the injury ;
for, beside the elevation of the patella, and its easy motion from
side to side, a deep depression is felt above the tubercle of the
tibia from the absence of the ligament ; the patient immediately
loses the power of bearing upon that limb, as the knee bends
under each attempt, and he would fall if he persisted in throwing
the weight of his body upon it, A considerable degree of
inflammation follows this accident.
In the treatment of this injury, local depletion and evaporating x,.eatment,
lotions are to be used during four or seven days from the accident,
and then a roller is to be applied around the foot and upon the
leg, to prevent its swelling ; the leg is to be kept extended by a
splint behind the knee, and a bandage, composed of a leathern
strap, is to be buckled around the lower part of the thigh ; to
A A 2
180 DISLOCATIONS OF THE KNEE.
this is to be attached another, whicli is to be carried on each side
of the leg, and under the foot, and is to be buckled to the
circular strap ; thus the bone is gradually drawn down, so as to
allow of an union of the ligament. In a month the knee may
be slightly bent, and as much passive motion daily given as
the patient is able to bear ; by these means the ruptured liga-
ment becomes united, and the patella retains its motion. During
the time the bandage is worn, the patient is to preserve the
sitting posture, in order to relax the rectus muscle and to prevent
its action upon the patella. With very great attention the union
becomes perfect; for so it happened in a case which I saw
with Mr. Burrowes, in Bishopsgate-street. Mr. B. paid great
attention to the case, and the patient recovered without any
diminution of the natural powers of the part ; the patella being
gradually forced down until the ends of the ligament had
approximated and coalesced.
Dislocation With rcspcct to dislocatiou of the patella downwards, at
downwards.
which some surgeons have hinted, I have seen no injury which
deserved such a title, if I except a rupture of the tendon of
the rectus, which I have twice witnessed, and which destroyed
the attachment of that muscle to the patella. The appearance
of this injury was a soft swelling above the patella, upon which,
when the hand was placed, it sunk into the joint ; the patella
fell loose between the condyles of the os femoris and the head
of the tibia, but it still retained very much its usual situation,
and could not be said to be luxated, as it was not displaced
from the joint. The treatment which this accident requires is,
that the patient be obliged to preserve a sitting posture during
DISLOCATIONS OF THE KNEE. 181
the cure ; and that a cushion be appHed upon the ligamentum
patellae, Avhich is to be confined by a roller passed around the
head of the tibia.
DISLOCATION OF THE TIBIA AT THE KNEE-JOINT.
These dislocations occur in four different directions ; but two of in four
them are incomplete, and lateral, while the others are perfect
luxations, the tibia being thrown either backwards or forwards.
The lateral dislocations are but rare. In the dislocation
inwards the tibia is thrown from its situation, so that the condyle internal.
of the OS femoris rests upon the external semilunar cartilage, and
the tibia projects on the inner side of the joint, so as at once to
disclose the nature of the injury. The first case of this kind
which I ever witnessed was brought to St. Thomas's Hospital
whilst I was an apprentice there, and I remember being struck
with three circumstances in it: the first was, the great deformity
of the knee from the projection of the tibia ; the second, the ease
with which the bone was reduced by direct extension ; and the
third, the little inflammation which followed upon what appeared
to be so serious an injury; for the man was discharged from
the hospital after a few weeks, having suffered little local or
constitutional irritation.
The tibia is sometimes thrown upon the outer side of the knee- External.
joint, the condyle of the os femoris being placed in the situation
of the inner semilunar cartilage, or rather behind it, when the
same deformity is produced as in the external dislocation. The
182 DISLOCATIONS OF THE KNEE.
reduction of the limb is equally easy with the former, and the
patient recovers with little diminution of the powers of the part.
It seems to me that in both these dislocations the tibia is rather
twisted upon the os femoris, so that the condyle of the os
femoris, with respect to the tibia, is thrown somewhat backwards,
as well as outwards or inwards.
CASE.
One of the aldermen of the City of London, riding down
Highgate-hill during the night, and not being aware of a rail that
was placed across a part of the road which was undergoing repair,
the horse ran against the rail, and, turning quickly, threw his
rider over it, whilst his leg was confined between the rail and the
horse, so that his body was on one side of the rail, and his leg on
the other : the result of this accident was, that he partially
dislocated his tibia outwards, throwing the condyle of the os
femoris inwards. Being immediately taken to a public-house,
the tibia was easily replaced; and on his removal home, some
hours afterwards, means were used to reduce the swelling and
inflammation, which became considerable. When he attempted to
bear upon the limb he found the capsular ligament very feeble,
and he was obliged to have a knee-cap made of very strong
leather, to support and connect the bones ; by the aid of this
bandage he gradually recovered, and was enabled to walk well,
and to do duty on horseback as a light-horse volunteer, before
twelve months had expired.
DISLOCATIONS OF THE KNEE. 183
CASE.
I was consulted by Mr. Richards respecting Mr. Bovill, a
gentleman from Barbadoes, who had dislocated his knee. I
made a few notes on the case at the moment, which were as
follows: The gentleman was thrown from a gig; the tibia was
dislocated, and the libula broken a little below its head. The <^^^^«f
dislocation
head of the tibia projected much on the inner side of the condyle '°'^"<^*-
of the OS femoris. My friends, Mr. Caddell and Mr. Richards,
surgeons at Barbadoes, saw him a quarter of an hour after the
accident; the leg was extended from the thigh-bone in a bent
position of the limb ; the extension was a long time continued,
and force was employed by several persons for half an hour before
the luxation was reduced. The limb became excessively swollen,
and remained so for many weeks, the climate probably being
unfavourable to his recovery ; but at length the inflammation and
its consequences were subdued by local depletion. When I saw
him eighteen months had elapsed from the accident, and he could
not then bend the joint at right angles with the thigh ; there was
also an unnatural lateral motion of the joint, from the injury
which the ligaments had sustained. The fracture of the fibula
had injured the peroneal nerve, as was evident from the numbness
of which he complained in the outer part of the leg and foot.
forwards.
The tibia is now and then dislocated in a direction forwards. In Dislocation
this accident, when the person is recumbent, the external marks of
the injury are these: The tibia is elevated; the thigh-bone is
depressed, and is thrown somewhat to the side as well as back-
wards; the OS femoris makes such pressure on the popliteal
184 DISLOCATIONS OF THE KNEE.
artery, as to prevent the pulsation of the anterior tibial artery on
the foot ; the patella and tibia are drawn by the rectus muscle
forwards. Such were the appearances in a man of the name of
Briggs, brought into Guy's Hospital in the year 1802, not only
with this accident, but with a compound fracture of the tibia of
the other leg, with dislocation of the head of the fibula. Mr.
Lucas was obliged to amputate the compound fracture, and the
man is now living at Walworth. The limb in this case was easily
reduced by extending the thigh from above the knee, and by
drawing the leg from the thigh, and inclining the tibia a little
downwards. As soon as it was reduced, the popliteal artery
ceased to be compressed, and the pulsation in the anterior tibial
artery was restored.
Dislocation Thc head of the tibia is sometimes dislocated backwards, behind
backwards,
the condyles of the os femoris, producing the following appear-
ances : A shortened state of the limb, a projection of the con-
dyles of the OS femoris, and depression of the ligament of the
patella, and the leg is bent forwards.
For the following case, I am indebted to my friend, Dr.
Walshman, who has ever been a man of close observation in
his profession, and always practised it with attention, judgment,
and honour.
CASE.
Case by Dr. Ml'. Luland, rcsidin^: near the Elephant and Castle, at New-
ington Butts, a very robust and muscular man, on the 4th of
January, 17^)4, dislocated his shoulder and knee at the same
instant. The accident happened in the following manner: It
was a severe frost, and the ground very slippery, and he being
Walshman.
DISLOCATIONS OF THE KNEE. 185
ill his cart, the horse fell. Mr. Luland was thrown under the
front rail of the cart, and luxated the tibia backwards, whilst his
shoulder fell on the saddle, and dislocated the os humeri into the
axilla. The head of the tibia was completely dislocated back-
wards, reaching behind the condyles of the femur into the ham ;
the tendinous connection of the patella to the rectus muscle was
ruptured; the external condyle of the os femoris was very pro-
tuberant ; the leg was bent forward and was shortened, and there
was a depression just above the patella. The patient felt most
excruciating- pain when the limb was moved, but there was
not any considerable degree of suffering when it was at rest.
The reduction was effected in the following manner: Two men
extended upwards, one from the groin, and the other from the
axilla, whilst two others extended the leg from a little above the
ancle in the opposite direction; and they gradually increased the
force of their extension till the bone was reduced. The patient
was placed on his back, and Dr. Walshman directed the head of
the bone to its natural situation. Dr. W. then applied a flannel
roller on the knee, placed the patient in bed with his limb upon a
pillow, and directed the part to be kept wet with an evaporating
lotion. He remained in this state a fortnight, free from pain ; the
Dr. slightly moved the part every other day, as far as he could
without giving pain. In about a month Mr. Luland began to walk
on crutches. Ten weeks after the accident he was able to sit at
his dinner-table, and in five months he had given up the use of
his crutches, and appeared perfectly recovered, being able to
use that limb as well as the other. He died of dropsy in
February, 1819,
B B
186 DISLOCATIONS OF THE KNEE.
Dr. Walshnian's treatment of this case was highly judicious
He suffered the parts, as he observes in his letter, to remain at
rest till the adhesive inflammation had united the lacerated
ligament, and then, and not till then, began with passive
motion.
PARTIAL LUXATION OF THE THIGH-BONE FROM
THE SEMILUNAR CARTILAGES.
From relax- Uudcr cxtrcme dcffrces of relaxation, or in cases in which there
ation. "
has been increased secretion into a joint, the ligaments become so
much lengthened, as to allow the cartilages to glide upon the
surface of the tibia, and particularly when pressure is made by the
thigh-bone on the edge of the cartilage. That excellent practical
Mr. Key's surffcon, the late Mr. Hey, of Leeds, whose death is severely
idea. ^ , .... .
deplored in the district in which he practised, and lamented by
those in the profession who have its improvement at heart, was
the first who clearly described the symptoms and cause of these
accidents, and suggested a mode of treatment which is ingenious,
scientific, and generally successful. The injury most frequently
occurs when a person in walking strikes his toe, with the foot
everted, against any projection (as the fold of a carpet), after
which he immediately feels pain in the knee, which cannot be
completely extended. I have seen this accident also happen from
a person having suddenly turned in his bed, when the clothes not
suffering the foot readily to turn with the body, the thigh-bone
DISLOCATIONS OF THE KNEE. 187
has slipped from its semilunar cartilage. I have also known it
occur from a sudden twist of the knee inwards when the foot
was turned out.
The explanation of this accident is as follows : The semilunar Explanation
. . , , ofthe
cartilages, which receive the condyles of the os femoris, are united acc'dem.
to the tibia by ligaments, and when these ligaments become
extremely relaxed and elongated, the cartilages are easily pushed
from their situations by the condyles of the os femoris, which
are then brought into contact with the head of the tibia ; and
when the limb is attempted to be extended, the edges of the
semilunar cartilages prevent it. How then is the bone to be
affain brought upon the cartilages ? Why, as Mr. Hey has Mode of
~ ^ ^ ... reduction.
advised, by bending the limb back as far as is possible, which
enables the cartilage to slip into its natural situation ; the pressure
of the thigh-bone is removed in the bent position, and the leg
being brought forwards, it can then be completely extended,
because the condyles of the os femoris are again received on the
semilunar cartilages. This plan is not however invariably suc-
cessful, as the following case will shew. A lieutenant in the army
suffered this accident repeatedly, and the limb was as often
reduced by the above means ; but at length in turning in bed,
from the pressure of the bed clothes on his foot, the accident
recurred. He came to town ; but bending the limb had now no
effect in enabling him to extend the joint, I therefore advised him
to visit Mr. Hey, at Leeds ; but I learnt that in this case the
dislocation was never reduced.
I made the following notes of the case of a gentleman who
came to my house. Mr. Henry Dobley, aged thirty-seven, has
B B 2
Different
mode of
reduction
188 DISLOCATIONS OF THE KNEE.
often dislocated his knee, turning- the foot inwards and the
thigh-bone outwards, by accidentally slipping in walking on
uneven ground, or by sudden exertions of the limb ; considerable
pain was immediately produced, accompanied with a great deal
of swelling. His mode of reducing it is as follows : He sits upon
the ground, and then bending the thigh inwards and pulling the
foot outwards, the subluxation of the os femoris being external,
the natural position of the limb becomes restored. A knee-cap,
laced tightly around the knee, is the usual preventive of the return
of this accident ; but it is not sufficient in Mr. Dobley without the
addition of straps, and more especially of a very strong one of
leather, just below the patella.
A young lady was brought to my house who was frequently
the subject of this accident, but in her the cartilages had been
several times easily replaced, and the return of the accident
Particular prevcutcd by a bandage composed of a piece of linen with four
required rollcrs attached to it, which were tightly bound above and below
the patella ; this, she said, answered its intended purpose better
than any other contrivance.
Great alteration takes place in the form and size of the knees,
in some of these cases, from a chronic rheumatism occasionally
attending them. I made the following notes of a case of this
kind, on which I was consulted, and I have seen others similar
to it.
CASE.
Lady D , a year and a half ago, fell and twisted her thigh-
bone inwards at the knee, producing great pain on the inner
side of the joint. Her ladyship immediately restored the parts
DISLOCATIONS OF THE KNEE. 189
to their situation by pressing the thigh outwards and the leg
inwards, previously to which she could not move the joint. For
a fortnight she was scarcely able to bend or straighten the
knee, and the muscles felt to her to be in a state of cramp.
She then began to stand upon the limb by the aid of crutches,
but when she bore upon it considerably it suddenly bent back,
with pain and subsequent swelling, and she felt the condyles at
the same time slip from the semilunar cartilages upon the head
of the tibia. Any sudden motion produced the same eifect for
fifteen months, and each of these accidents retarded her recovery
for several weeks; the pain extended from the knee to the toe.
For three months previous to her last accident, she walked on
crutches, and even sometimes with only the aid of a stick ;
when, about two months since, in endeavouring to raise herself
from a sofa, the left knee gave way as if the bone had slipped
from its place, the thigh-bone being at the time twisted outwards ;
pain and swelling succeeded, and she has never been able to
stand upright since. Her joints are all of them remarkably
flexible, as the elbow may be easily bent backwards to form
an angle with the os humeri. When a girl, she had frequently
the sensation of putting the knees out of joint, but they soon
got well. The knees are now swollen, and effusion of a consi-
derable quantity of synovia has taken place into the joints. When
she attempts to stand she cannot straighten her knees, but would
fall forwards if unsupported. The principal object in the treat-
ment is, to produce absorption of the fluid which is effused,
and then to give due support to the ligaments. For the first
of these she was desired to apply blisters, which were directed
190 DISLOCATIONS OF THE KNEE.
to be kept discharging for a considerable time, and after they
were healed, she was ordered to make pressure upon the joints
by a strong bandage, which was to be occasionally removed to
give an opportunity of employing friction. But she received
material benefit from a constitutional treatment, consisting of
pil. hydrargyri submuriatis comp., with decoctum sarsaparillae
compositum, and locally from the continued use of friction. I
have had lately the pleasure of seeing her perfectly recovered.
In the dissection of these cases, the ligament is found extremely
thickened ; little pendulous ligamentous and cartilaginous bodies
are seen suspended from it ; a thick edge of cartilage projects
from the articular cartilage, and a part of the latter is absorbed.
When the bone is macerated, a great addition of ossific matter
is found to have been made to the edges of the condyles of the
OS femoris.
DISLOCATION OF THE KNEE-JOINT.
Cases of dislocation of the knee-joint are so rare, that every
instance of this accident is worthy of recital ; and I feel greatly
indebted to my friend, Mr. Toogood, surgeon at Bridgewater, for
the following detail of one which occurred under his care.
CA8E.
December 5th, 1806.
Francis Newton, a strong athletic man, thirty years old, fell
from the fore part of a waggon, heavily laden with coals, and
DISLOCATIONS OF THE KNEE. 191
entangling his foot in the frame-work of the shaft, was dragged
for a very great distance before he was released. I saw him two
hours after the accident. The left knee was very much swollen ;
the tibia, fibula, and patella were driven up in front of the thigh ;
and the os femoris occupied the upper part of the calf of the leg,
the internal condyle being nearly through the skin. It was a
complete dislocation, and the appearance of the limb so dreadful,
that I despaired of being able to reduce it ; but, to my surprise, it
was more easily effected than I imagined. By placing two men
to the thigh whilst I extended the leg, the man became directly
relieved. The whole limb was placed in splints, and the strictest
antiphlogistic treatment observed, with the most perfect quiet.
The symptoms were very mild : and, by carefully watching him,
he suffered very little inflammation or pain. At the expiration of
a month I allowed him to get up, and on the 29th of January, he
came into this town, a distance of four miles, ^n a cart, and
walked from an inn to my house, with his leg but little swollen,
and having some motion of the joint. He eventually irecovered a
very good use of his limb, and walks with so little inconvenience
that he has followed his business as a waggoner ever since ; and
this day, November 30th, 1822, I have seen him walking by the
side of his team with very little lameness.
COIMPOUND DISLOCATION OF THE KNEE-JOINT.
Of this I have only seen one instance, and I conclude it,
therefore, to be a rare occurrence ; and there are scarcely any
192 DISLOCATIONS OF THE KNEE.
accidents to which the body is liable which more imperiously
demand immediate amputation than these.
CASE.
On Monday, August 26th, 1819, at eleven, p. m., I was sent
for by Mr. Oliver, surgeon, at Brentford, to visit Mr. Pritt,
who had fallen from the box of a mail-coach, and most severely
injured his knee. I met, at the house to which he was carried,
Mr. Oliver, and Mr. Hunter, of Richmond, surgeons, and imme-
diately proceeded to examine the knee. A large opening was
found in the integuments, through which the external condyle
of the OS femoris projected, so as to be on a level with the edges
of the skin. The os femoris was thrown behind the tibia on the
outer side of the head of the latter, and the external condyle of
the thigh-bone Avas dislocated backwards and outwards ; the thigh-
bone was twisted outwards, and the internal condyle advanced
upon the head of the tibia. I made attempts to reduce the
condyle, but it could only be effected with extreme difficulty ;
and the bone, directly when the extension was removed, slipped
into its former situation. The joint being freely opened by the
accident, the bone dislocated, and when reduced easily slipping
from its place, and the patient having an extremely irritable
constitution, decided me at once to propose the amputation of
the limb, which, being acceded to, was immediately performed.
The symptoms of constitutional irritation which followed the
operation became extremely severe, and he being delirious on
the 31st, Mr. Oliver applied leeches to his temples, a blister
under the occiput, and gave the saline medicine with the camphor.
DISLOCATIONS OF THE KNEE. 193
and the pulv. ipec. comp. On the following' day I was sent for
to visit him, but being absent from London, my most able and
excellent friend, Mr. Cline, visited him, and ordered him tine,
opii. gtt. V. — Pulv. castor, gr. x. — Mist, camphor, siss. m. — Ft.
haustus 4ta quaque hora sumendus. Soon after the second
draught was administered he fell asleep, and after several hours
repose awoke perfectly sensible. He gradually recovered, and
left Brentford on the 25th of October, with a small wound
still remaining on the stump.
I brought home the limb, and carefully dissected it. Under
the skin there was great extravasation of blood in the cellular
membrane surrounding the knee ; the vastus internus muscle
had a large aperture torn in it just above its insertion into the
patella ; the tibia projected forwards ; and the patella was drawn
to the outer side of the knee, being no longer in a line with the
tubercle of the tibia. Looking at the joint posteriorly, both
heads of the gastrocnemius externus muscle were lacerated;
the capsular ligament was so completely torn, posteriorly, that
both the condyles of the os femoris were seen projecting through
the laceration in the gastrocnemius ; neither the sciatic nerve,
the popliteal artery and vein, the lateral, nor the crucial ligaments,
were ruptured. (See plate.)
It is probable that all compound dislocations of the knee-joint
will require a similar practice, unless the wound be so extremely
small as to admit readily of its immediate closure and adhesion.
G C
Dissection.
194 DISLOCATIONS OF THE KNEE.
DISLOCATION OF THE KNEE FROM ULCERATION.
Ligament
ulcerated.
In the progress of chronic diseases of the joints, inflammation
beginning" in the synovial membrane, and proceeding to ulcerate
the articular cartilages and bone, at length affect the capsular
ligament, and sometimes even the peculiar ligaments of the joints;
the bones thus becoming unconnected, the muscles irritated by
participating in the inflammation, draw the limb into distorted
positions, and thus one bone becomes gradually displaced from
the other. This state is most frequently seen in the hip-joint,
from the oblique bearing of the thigh-bone on the pelvis. In the
knee it is also not unusual that the thigh-bone shall be placed out
of its natural line with the tibia, projecting either on the one side
or the other.
Now and then most remarkable distortions are produced by the
irritative and spasmodic action of the muscles succeeding the
ulcerative process of the ligaments, of one of which I have given
a plate ; Mr. Cline removed it by amputation in St, Thomas's
Hospital. It had been the consequence of what is vulgarly
called the white swelling of the knee-joint ; the leg was placed
forwards at right angles with the thigh, so that when walking
on his crutches he had the most grotesque appearance, as the
bottom of his foot first met the eye when he was advancing.
Upon inspection of the patella it was found anchylosed to the
OS femoris, and the tibia was also joined by ossific union to the
fore part of the condyles of the thigh-bone. (^See plate.)
venTedT This stato of parts may be prevented by opposing the action of
Excessive
distortion.
DISLOCATIONS OF THE KNEE. 195
the muscles when their irritability first begins to produce dis-
tortion ; by the application of splints ; and by the exhibition
of the pulvis ipecacuanhse compositus, to diminish the irritability
of the system. Thus I have seen, in cases of ulceration of the
hip-joint, the irritative action of the flexor muscles diminished,
and future distortion prevented, by drawing down the limb and
keeping it in the extended position ; but as this extension is
most painful to the patient, however desirable it may be, it
should be accomplished very gradually.
C C 2
FRACTURES OF THE KNEE-JOINT.
I SHALL now, pursuing my former plan, describe the fractures
to which the bones entering into the composition of this part are
liable ; and first the
FRACTURES OF THE PATELLA.
Transverse This bonc is generally broken transversely, sometimes, though
^^^- rarely, longitudinally: it is liable also to simple and compound
fracture, but, fortunately, the latter is but of rare occurrence.
Symptoms. Whcu thc patella is transversely broken, the upper part of
the bone is drawn from the lower, its superior portion being
elevated by the action of the rectus, vasti, and cruralis muscles,
which are inserted into its upper part; whilst the lower portion
is still retained in its natural situation by the ligament which
passes from it to the tubercle of the tibia.
Degree of Thc dcgrcc of Separation, thus produced, depends on the
extent of laceration of the ligament; for, when the ligament
separation.
FRACTURES OF THE KNEE. ]97
is but little torn, the separation will be half an inch, but under
great extent of injury the bone is drawn five inches upwards,
the capsular lig-ament and tendinous aponeurosis covering it
being then greatly lacerated ; and this, with one exception, is
the greatest extent of separation which I have seen. The
accident may be at once known by the depression between the
two portions of bone ; the fingers passing readily down to the
condyles of the os femoris, into the joint as far as the integu-
ments will permit ; and the elevated portion of bone moving
readily on the lower and fore part of the thigh. The power
of extending the limb is lost immediately after the accident,
and likewise that of supporting the weight of the body on that
leg, if the person be standing ; for the knee bends forwards
from the loss of action in the extensor muscles. The pain
of this accident is not very severe, and a simple fracture is
not dangerous, for the constitution feels it but little. In a few
hours after the accident, a copious extravasation of blood takes
place upon the fore part of the joint, so that the appearance is
livid from ecchymosis, but this is removed by absorption in a
few days. Considerable inflammation and fever succeed, and
there is a great degree of swelling in the fore part of the
joint, both from the free secretion of synovia, and the effusion
arising from inflammation. No crepitus is felt in this fracture,
for the bones cannot be sufficiently approximated to evince this
general discriminating mark of other fractures.
The separation of the bones is much increased by bending the
knee, as this act removes the lower from the upper portion of
198 FRACTURES OF THE KNEE.
bone, pulling down the tibia, llgamentiim patellae, and the lower
part of the bone from the upper.
Causes. This accident arises from two causes : first, from blows upon
the bone produced by falls upon the knee, or received upon the
Blows or patella in the erect position of the body; and, secondly, from
actions of the
muscles. thc actiou of the extensor muscles upon the bone.
Case. A gentleman walking* in the country, and not used to jumping,
leaped a ditch of considerable breadth ; and when he reached
the opposite bank, being in danger of falling, he ran forward
several steps, and with difficulty recovered himself; in this
attempt to save himself from a fall, he felt the patella snap.
I was sent for to him, and found his patella broken, and the
portions of bone considerably separated.
A lady, descending some stairs, placed her heel near the edge
of one of the stairs, and was in danger of falling forwards, when,
throwing her body somewhat backwards to prevent the fall and
to straighten the knee, the patella became broken.
That a bone should thus break by the action of muscles appears
at first sight incomprehensible, but this circumstance is easily
Explanation, explained. When the knee is bent, the patella is drawn down on
the end of the condyles of the os femoris, so as to bring the upper,
edge of the bone forwards ; and at that moment it is that the
patella is broken, by the rectus muscle acting not in a line with
the bone, but at right angles with it, or nearly so, and upon its
upper edge more particularly.
Mode of With respect to the union of this bone, whether the separa-
tion be great or inconsiderable, it is generally effected by an
union.
FRACTURES OF THE KNEE. 109
intervening lig-amentous substance. The bone itself undergoes
but little alteration ; the lower portion, joined by ligament to the
patella, has its broken cancellated structure still apparent, although
a little smoothed. The upper portion of bone has its broken
cancelli covered by a slight ossific deposit, so that there is more
ossific action in the upper than in the lower portion of the bone,
and certainly much less than in bones which do not form a part
of the joints. The internal articular surface of the bone preserves
its natural smoothness. Blood is immediately deposited in the
place of the injured ligament, but this in a few days is absorbed.
Inflammation arises and pours out adhesive matter, which extends
from one edge of the lacerated ligament to the other, and even
between the bones, to each of which it is firmly united. (See
plate.J Vessels shoot from the edges of the ligament and render
the new substance organized, producing a ligamentous structure
similar to that from which the vessels shoot ; this substance is not,
however, always perfect, for I have seen apertures in it; but this
will greatly depend upon the extent of the laceration of the
ligament, and the too early use of the limb. In the dog and in
the rabbit, or almost any other quadruped, it is possible by
experiment to trace the mode of union of this bone.
Experiment I.
I drew the integuments much aside in a rabbit, and dividing
them, placed a knife upon the patella and struck it lightly with
a mallet ; the bone was broken and directly drawn up by the
action of the muscles. I let the integuments go, and the wound
200 FRACTURES OF THE KNEE.
was not opposite to the fracture. In forty-eight hours I killed the
animal and examined the part : the bones were separated three
quarters of an inch, and the intervening part filled with coagulated
blood.
Experiment II.
I repeated the former experiment, and having killed the animal
on the eighth day, found most of the blood absorbed, and adhesive
matter occupying the space between the bones.
Experiment III.
The former experiment repeated. The animal examined on the
fifteenth day. The adhesive matter had acquired a smooth and
somcAvhat ligamentous character.
Experiment IV.
The same division of the bone being made, it was examined on
the twenty-second day, when the new ligament was complete.
Experiment V.
The same repeated, and the examination made in five weeks.
The part was injected, and vessels were found proceeding from
the edge of the ligament into the adhesive matter, now become
ligamentous. So that at the end of five weeks the vascularity is
complete, and some vessels proceed into the new ligament from
the bone, but chiefly from the lacerated ligament. Upon the dog
these processes may be equally well observed, but they are not
quite so rapidly produced in a large dog as in the rabbit.
I
FRACTURES OF THE KNEE. 201
The parts were dissected and preserved after these experiments,
both in the dog and rabbit, and they are deposited in the collection
of St. Thomas's Hospital, where they may be always seen.
Experiment VI.
In the rabbit, having divided the bone, I sewed the two
portions by conveying" a needle and thread through the tendinous
covering of the bone, but the ligatures separated, and the bones
still united by ligament.
Experiment VIl.
I divided the bone, and cut the rectus muscle across above it,
yet the patella united by ligament.
I could not, either in the dog or rabbit, succeed in producing
a bony union in the transverse fracture. Yet in a patient of
my kind friend, M. Chopart, at Paris, I once saw a case which
appeared to me to be united by bone ; and Mr. Fielding, of Hull,
has lately published a similar case.
A ligamentous union of the transverse fracture of the patella is
that which generally occurs : and if there be an exception it is
very rare. But still the principle which is to guide the surgeon's
conduct is, to make that ligament as short as possible. If the Ligamentous
ligament be of great length there is a proportionate weakness ; short as pos-
sible.
for as soon as the accident has happened, the rectus muscle retracts
and draAvs up the superior portion of the patella ; and in proportion
to the retraction suffered to remain, is the degree of shortening of
the muscle, and consequently the diminution of its power. Those,
D D
202 FRACTURES OF THE KNEE.
therefore, in whom the bones have united after being widely-
separated, if they walk quickly, do it with a halt, and are very
liable to fall, and to break the other patella. Let then the
muscle be brought as nearly as it can be to its natural length ;
and although complete apposition of the bone be very rarely
effected, yet the ligamentous union is rendered as short as cir-
cumstances will permit, and the patient will recover the power
of the limb.
The notion which was formerly entertained of the danger of
squeezing the callus into a projection in the inner side of the
bone, so as to destroy the smoothness of its internal surface, is
not at all tenable.
Treatment. When Called to this accident, the surgeon places the patient in
bed upon a mattress, extends the limb upon a well padded splint
placed behind the thigh and leg, to which it is tied, and Avhich
should be hollowed. The patient's body should be raised as
much as he can bear to the sitting posture, to relax the rectus
muscle. An evaporating lotion is to be then applied upon the
knee, consisting of liq. plumbi s. ecetat. dilut. s. v. with spir. vini.
3. i. ; and no bandage should be at first employed. The body
should be slightly raised in bed to relax the rectus muscle, and
the heel should be raised to bring up the lower portion of the
patella. If in a day or two there be much tension or ecchymosis,
leeches should be applied, and the lotion be continued ; when, after
a few days, the tension has subsided, then, and not till then, should
bandages be employed. I have seen the greatest suffering and
swelling produced by the early application of bandages in these
cases, even so as to threaten sloughing of the skin when there had
FRACTURES OF THE KNEE. 203
been much contusion. The means which are most frequently
employed in the treatment of this case are as follows : A roller
is applied from the foot to the knee, to prevent the swelling of the
leg', and the upper portion of bone is pressed downwards, as far as
it can be without violence towards the lower, so as to lessen the
retraction of the muscles, and produce the approximation of the
portions of bone. Then rollers are applied above and below the
joint, confining a piece of broad tape next the skin on each side,
which crosses the rollers at right angles ; these portions of tape
are bent down and tied over the rollers so as to bring them near
each other, and thus to keep down the upper portion of bone.
Sometimes, instead of the tape on each side, a broad piece of linen
is bent over the rollers on the fore part of the joint, and is there
confined, so as to approximate the pieces of bone, and to bind
down the upper portion of the patella, that its lower broken edge
may not turn forwards.
But the mode I prefer is as follows : A leathern strap should be
buckled around the thigh, above the broken and elevated portion
of bone ; and from this circular piece of leather another strap
should be passed under the middle of the foot, the leg being
extended, and the foot raised as much as possible. This strap is
brought upon each side of the tibia and patella, and buckled to
that which is fixed around the lower part of the thigh. The strap
may be confined to the foot by a tape tied to it, and to the leg at
any part in the same manner ; this is the most convenient bandage
for the fractured patella, and for the patella dislocated upwards by
the laceration of its ligament. A roller is to be applied upon
the leg.
D D 2
204 FRACTURES OF THE KNEE.
In this position, and thus confined, the limb is to be kept for
five weeks in the adult, and for six weeks at a more advanced
age. Then a slight passive motion is to be begun, and this must
be done gently and with so much circumspection that the liga-
ment, if not firmly united, shall not give way, and suflfer the bones
to recede. If the union be found sufficiently firm to bear it, the
passive motion is to be employed, from day to day, until the
flexion of the limb be complete.
If passive motion were not used it appears that the action of the
extensor muscles would never return ; for those who are kept in
bed, with the joint at rest, do not in many months acquire any
power of bending and extending the limb ; but when passive
motion is to be used the patient is placed on a high seat, and
directed to swing the leg, by which motion is given to the rectus ;
and if the mind be then directed to the contraction of that muscle,
its powers will be gradually renewed. When the rectus muscle
has been shortened, and the upper portion of bone is drawn from
the lower, all the disposition to action in that muscle ceases ; and
it does not seem disposed to recover its voluntary action until it
becomes again elongated, which effect takes place after the union
of the ligament by bending the knee ; and from this point of
elongation the muscle begins to contract.
A young woman was brought into ray house in her father's
arms, and he said, " I am obliged to carry her, for she has lost
the use of her legs, having broken both her knee-pans eight
months ago, and she has never been able to use her limbs since."
Passive motion was directed, and she was ordered to try to extend
her legs after they had been bent by the surgeon. At first she
State of the
muscle.
FRACTURES OF THE KNEE. 205
could effect but little : however, by repeated trials, she g-radually
recovered the use of her limbs. Mr. John Hunter, who raised
surg'ery into a science, and who seems to have been the first who
attended to the principles on which the practice of surgery ought
to be regulated, always dwelt most ably upon this subject in his
lectures. Patients, from the pain which passive motion produces,
and the slow return of action in the muscles, are indisposed to
suffer the one or to make trials of the other; but without them
there can be no recovery.
The degree of approximation of the bone is, as I have stated, a Degree of
approxi-
raatter of great consequence. The bone is rarely brought into motion.
contact so as to be united in the transverse fracture by ossific
union, but the less the distance between the bones the greater is
the power which the muscle re-acquires ; for in proportion as the
muscle is shortened it is weakened ; and in ascending- there is
difficulty in raising the limb, in descending in keeping it extended;
the uniting ligament is liable to be torn, and the other patella
to be broken by falls ; therefore the surgeon should bring the
bones as near together as he can, to render the ligamentous union
as short as possible, and consequently to leave the muscle with as
much of its original power as the nature of the accident will
permit.
THE PERPENDICULAR FRACTURE OF THE
PATELLA.
We have in the collection at St. Thomas's Hospital a patella,
one fourth of which has been broken off; the edge is smooth, and
no attempt at ossific union appears to have been made.
206 FRACTURES OF THE KNEE.
A gentleman consulted me who had about one third of the
Sr"*""^ patella separated from the other part of the bone ; it had united
by ligament, for there was free motion between the fractured
piece of bone and that from which it had been removed. He
recovered quickly from this injury, and it affected his power of
walking very little.
During the winter of 1822, a body was dissected at St. Thomas's
Hospital, in which both the patellae had been broken longitudinally,
and although they were in contact, they were both united by
ligament. Mr, Silvester, one of our pupils, had the kindness to
make a drawing of one of these, of which I have given a plate.
This circumstance surprised me, because I saw no reason why
the patella should not be united by bone when broken perpen-
dicularly, as I thought the muscles would have a tendency to
bring' the parts together. I made it, therefore, a subject of
experiment.
Experiment I,
July 31st, 1818, I broke the patella of a dog by placing a
knife upon it in the longitudinal direction, having first drawn
the integuments aside ; and on the 12th of September following
I examined the part, when I found the two portions of bone
Union by cousidcrably separated from each other, and united by ligament.
e'Iprrfment's. The causc was as follows : When I had divided the bone, the knee
became bent, the condyles of the os femoris pressed against the
inner side of the patella, and thrust the parts asunder, and only a
ligamentous union took place. (See plate.)
EcVjieriment II.
August 2nd, 1818, I broke in the same manner the patella of a
FRACTURES OF THE KNEE. 207
rabbit, and exaiiiined the parts on September 3rd, when I found
the two portions of bone widely separated, and united only by
ligamentous matter. I now began to think it impossible for the
patella to unite by bone, but determined to make another experi-
ment to determine this point.
Experiment III.
I divided the patella longitudinally in a dog, but took care that
the division should not extend into the tendon above or to the
ligament below it, so that there should be no separation of the
two portions. I examined it three weeks after, and found it
united ; no separation existing between the two portions.* {See uni"" ^y
plate.)
Experiment IV.
October, 1819. I divided the patella by a crucial fracture into
four portions ; the two upper portions neither united with each
other nor with the bones below, but the two lower portions
became united by bone.
It appears then that under longitudinal and transverse fracture,
a ligamentous union is generally produced, and that it arises
from the separation produced in the bone ; but that if that cannot
separate, and its parts remain in contact, ossific union may be
produced.
In the summer of 1819, Mr. Marryat was thrown from his gig
* The bone was, under maceration, found united in part by bone, and in part by cartilage, not yet
completely ossified. It is preserved, and may be seen at any time by those who are curious to
examine it. •
208 FRACTURES OF THE KNEE.
as he was passing along the Strand ; by the fall he fractured his
patella transversely, and the lower portion of the bone was also
broken perpendicularly, so that it was divided into three pieces.
The transverse fracture united, as usual, by ligament ; but the
perpendicular, by bone.
Mr. Parrott, of Tooting, who also attended the case, writes in
these words :
" Dear Sir, — I have great pleasure in replying to your
letter. The longitudinal fracture of the patella of Mr. M. has
become very firmly consolidated, but there is a line or ridge to be
traced upon the surface of the bone, which marks distinctly the
place where it had been separated.
" John Parrott, Jun."
Tooting.
Treatment. jjj ^[jg lougitudiual or perpcudicular fracture of the patella, the
best treatment consists in extending the leg, and in using local
depletion, and evaporating lotions ; in a few days a roller should
be applied around the limb, and then a laced knee-cap, with a
strap to buckle around the knee above and below the patella, and
a pad on each side to bring its parts as nearly as possible into
contact.
COMPOUND FRACTURE OF THE PATELLA.
From These fractures occur from injury, or from an ulcerative
violence or i/ .*
ulceration.
process under peculiar circumstances.
FRACTURES OF THE KNEE. 209
The cases which I have seen of this accident are as follows :
CASE I.
A man was admitted into Guy's Hospital, in the year 1796,
under Mr. W. Cooper, surgeon of that hospital, with a compound
fracture of this bone ; violent inflammation followed ; suppu-
ration ensued, with the highest degree of constitutional irritation ;
and as no opportunity was given for amputation, from the great
swelling of the thigh, this man died. The bone is in the
Museum of St. Thomas's Hospital, disunited as at the first
moment of the accident.
CASE n.
A man was admitted into St. Thomas's Hospital, under the
care of Mr. Birch, with a fracture of the patella, and a small
wound extending into the joint. The knee was fomented and
poulticed ; inflammation and suppuration followed ; and this man
in a few days died with the highest symptoms of constitutional
irritation.
CASE HI.
Mr. Hawker, surgeon, called me to visit a man who had just
arrived in London; who, being at work in a warehouse up one
pair of stairs, on hearing the signal for dinner, seeing the
doors of the warehouse open, walked quickly out, and fell into
the street. By this fall he had a compound fracture of the
patella. The limb was attempted to be saved. The joint sup-
purated ; the discharge became excessively great ; and the
symptoms of irritation ran so high, that I thought he would
E E
210 FRACTURES OF THE KNEE.
not recover ; but he became somewhat better, and I advised
him to g'o into the country. I afterwards heard that he gradually
recovered with an anchylosed joint.
CASE IV.
Mr. Redhead, residing* at Kennington Cross, aged thirty-nine
years, was thrown from his gig, on June I8th, 1819, against a
cart-wheel. His knee came violently in contact with the wheel,
which fractured his patella and opened the joint. Mr. Dixon, of
Newington Butts, was sent for, and he found that the knee had
bled freely from a wound on its outer side, from which the synovia
freely escaped, and which readily admitted his finger to the
shattered patella. The accident happened at ten o'clock in the
morning" : I was sent for by IMr. Dixon, and when I met him at
four o'clock, I found a wound on the fore part of the knee, through
which I readily passed my finger into the joint. The patella was
not broken transversely, but, as I have expressed it, shattered ;
that is, broken into several pieces ; and a small piece which
was separated from the rest I removed. It was agreed between
Mr. Dixon and myself, that an attempt should be made to save the
limb, for the patient was of a spare habit, and, from his great
composure, shewed that he was not of an irritable constitution. I
passed a suture through the integuments, knowing the difficulty
of keeping the wound closed on account of the continued escape
of synovia, but taking the utmost care that the ligament should
not be included in the suture. Adhesive plaster was also applied
over the wound, and rollers lightly put on, which were kept con-
stantly wet with spirits of wine and water. The leg was placed in
FRACTURES OF THE KNEE. 211
the extended position, and he was ordered not to move it in the
slig-htest degree, and to live on fruit.
Saturday. He had passed a very good night, and was free
from pain or fever.
Sunday night. He was restless, and was thought delirious.
Monday morning. He had a dose of ol. ricini, which relieved
him from his feverish feelings.
Tuesday. He stated he had passed a good night, and he after-
wards had no bad symptoms. As there was no swelling, no inflam-
mation, and scarcely any pain, the suture was not removed until
the 30th of June, when the adhesive plaster was renewed.
He recovered without any untoward accident. Mr. Dixon
ordered him from bed in a month, and at the end of five weeks
gave the joint slight passive motion. On the 7th of August, the
patient walked across his room ; and he entirely recovered the use
of his limb.
If the laceration be extensive, or the contusion very considerable
in these cases, amputation will be required ; but if the wound be
small, and the patient be not irritable, and no sloughing of the
integuments or ligament be likely to occur from the nature of the
accident, it will be best to try to save the limb ; and the treatment
of Mr. Redhead's case is that which I should pursue. The prin-
cipal object is to produce adhesion immediately ; and every means
in our power must be used for that purpose. I know well that
sutures are generally objectionable, and I never employ them if I
can possibly succeed without them ; but in moveable parts, in
those which are unsupported, and in those through which a
E E 2
212 FRACTURES OF THE KNEE.
secretion is liable to force its way, they are not only justifiable,
but highly necessary. Fomentations and poultices must not be
employed in these cases, as they prevent the adhesive process.
A compound fracture of the patella will be sometimes produced
by an ulcer, as in the following case.
CASE.
A woman was admitted into Guy's Hospital in 1816, with a
simple and transverse fracture of the patella, which had long been
united by a ligament of about three inches in extent. Ulcers were
formed upon different parts of the body ; and, unfortunately, one
of these upon the integuments over the ligamental union of the
patella. It became sloughy, and extended through the new
ligament to the joint, which it laid open ; violent constitutional
irritation succeeded ; a copious suppuration was produced ; and no
opportunity was given of amputating the limb, for the inflamed
and swollen state of the thigh forbade it. This woman died.
Ulceration.
OBLIQUE FRACTURES OF THE CONDYLES OF THE
OS FEMORIS INTO THE JOINT.
These cases are of rare occurrence ; but when they happen it
is difficult to prevent deformity, and to restore to the patient a
sound and useful limb. They are known by the great swelling
of the joint Avith which they are accompanied, by the crepitus
which is felt in moving the joint, and by the deformity with which
FRACTURES OF THE KNEE. 213
they are attended. The fracture is sometimes of the inner, and ofeither
'' condyle.
sometimes of the outer condyle, and the bone is split down into
the joint.
Whether the external or internal condyle be broken, the same
treatment is required. The limb is to be placed upon a pillow in Treatment.
the straight position, and evaporating lotions and leeches are to
be used to subdue the swelling and inflammation. When this
object has been effected, a roller is to be applied around the knee,
and a piece of stiff pasteboard, about sixteen inches long and
sufficiently wide to extend entirely under the joint, and to pass on
each side of it, so as to reach to the edge of the patella, is to be
dipped in warm water, applied under the knee, and confined by a
roller. When this is dry, it will have exactly adapted itself to the
form of the joint, and this form it will afterwards retain, so as best
to confine the bones. Splints of wood or tin may be used on each
side of the joint, but they are apt to cause uneasy pressure. In
five weeks passive motion of the limb may be gently begun, to
prevent anchylosis. I prefer the straight position in these cases,
because the tibia presses the extremity of the broken condyle into
a line with that which is not injured.
Examples of compound fractures of the condyles are veiy compound
unfrequent: the following was under the care of Mr. Travers, in
St. Thomas's Hospital, who was so kind as to send me the history
of it.
Michael Dixon was admitted into St. Thomas's Hospital, Sep-
tember 17th, 1816, for a fracture of the lower extremity of the
femur, caused by a carriage-wheel in motion, with which his legs
214 FRACTURES OF THE KNEE.
became entangled. There was much displacement of the fractured
bone, and a small wound opposite the external condyle. Upon
examination it was evident that the fracture had extended nearly
in the direction of the axis of the bone, and there was a transverse
fracture of the shaft of the bone above the joint ; the external
condyle was moveable, and thrown out of its place during the
accident, as if it had been drawn by the leg, which was twisted
inwards. The limb was laid in a fracture-box, in a semi-flexed
position on the heel ; the constitutional disturbance was very
slight.
Oct. 5. The external condyle is still moveable : the integu-
ments over it are ulcerated, so as to denude the bone. The health
remains good.
Nov. 5. The broken bone protrudes and appears to be dead ;
it is surrounded by fungous granulations, and there is but little
discharge.
Nov. 18. The protruded bone having been gently twisted off
by forceps, proved to be the external condyle, with its articular
surface : there still protruded a small portion of bone, but this
soon healed over. The limb was now placed in an extended
position, as anchylosis was considered unavoidable.
Dec. 1. The boy has recovered almost the perfect use of his
limb, and is enabled to bend and extend it without pain.
Dec. 6. The boy was discharged from the hospital. The
wound was healed, and he can walk tolerably well with a stick.
On the February following he called at the hospital, walking
without any support, and having free use of the joint.
FRACTURES OF THE KNEE. 215
In aged persons these accidents sometimes prove destructive to
life, of which the following* is an example ; and, indeed, I have
known a simple fracture of the condyles produce the same effect.
of
COMPOUND FRACTURE OF THE CONDYLES OF
THE FEMUR.
CASE.
— Blukwick, aged seventy-six, on the 1st of January, 1822, f^°^jP°^*5
slipped accidentally off the curb-stone, and received the whole <=*'°''y'^'-
weight of the body upon the knee. The patella appears to have
acted as a wedge between the two condyles of the os femoris,
which were separated by a fracture, running obliquely along the
shaft of the bone, the end of which was forced through a wound
in the integuments. The patella remained in its place, and was
unbroken. The patient at the time of the accident was in a state
of inebriation. Mr. Rowe, of Burton Crescent, to whom I am case by
Mr. Rowe.
indebted for the particulars of the case, saw him about three hours
after the accident: he had him conveyed to bed, and without
much difficulty brought the fractured bones in apposition ; they
were retained in their situation by splints and bandages, and the
limb was placed in the straight position. A lotion of the liquor
plumbi was applied over the part, and an opiate was administered
at night.
The patient passed a tolerable quiet night, and in the morning
was pretty free from pain. An aperient draught was administered,
216 FRACTURES OF THE KNEE.
which operated freely. On the evening of this day I was called
in to him. I directed a leathern cap to be strapped over the
fractured part, and the straight position of the limb to be pre-
served. The patient was ordered a regular diet, and saline
draughts, with an occasional opiate.
This treatment was continued until the twenty-first day from
the accident, and the patient remained free from any bad symptom.
On the evening of that day, however, he was found much heated,
with a very frequent pulse, dry tongue, and a tendency to
delirium : these alarming symptoms, it appears, were increased by
a glass of brandy and water taken contrary to the direction of his
medical attendant. Mr. Rowe ordered him an aperient, but the
danger was rapidly increasing : the patient was found next morn-'
ing in a high degree of fever ; pulse one hundred and thirty ;
countenance exhibiting great depression. These unfavourable
symptoms went on increasing, and on the twenty-fourth he died.
The limb, on examination after death, exhibited great signs of
inflammation ; a considerable quantity of matter was found between
the muscles of the thigh, part of which was discharged by the
external wound.
Dissection.
Upon examining the thigh-bone it was found that its shaft was
broken very obliquely, about seven inches above the knee-joint ;
and that the bone was split down into the joint, near to the centre,
between the condyles, but inclining somewhat to the external
condyle : this portion of the bone was loose and detached from
the internal condyle: there was also a piece three inches in extent.
^ FRACTURES OF THE KNEE. 217
detached from the shaft of the bone, but which had fallen into
the cancelli, where it remained lodged. (See plate.)
OBLIQUE FRACTURES OF THE OS FEMORIS, JUST
ABOVE ITS CONDYLES.
This is a most formidable injury from its consequences on the obiique
future form and use of the limb ; for it is liable to terminate most the condyles.
unfortunately, by producing deformity, and by preventing the
flexion of the knee-joint.
Tt is only of late years that I have had an opportunity of inves-
tigating this case by dissection, and, consequently, of obtaining
substantial knowledge of the exact nature of the injury. The
appearances produced by it are, that the lower and broken ex-
tremity of the shaft of the bone projects, and forms a sharp
point just above the patella, which pierces the rectus muscle,
threatens to tear the skin, and sometimes does so ; whilst the
patella, tibia, and condyles of the os femoris sink into the ham,
and are drawn upwards behind the broken extremity of the shaft
of the OS femoris.
The accident happens when a person falls from a considerable
height upon his feet, or is thrown upon the condyles of the os
femoris with the knee bent. In all the cases, the fracture was
very oblique through the shaft of the bone ; and hence the
pointed appearance of the extremity of the fracture, and the
difficulty of keeping the bones in apposition,
F F
218 FRACTURES OF THE KNEE.
CASE.
Case. A body was brought into the dissecting-room at St. Thomas's
Hospital, which fell to the lot of Mr. Patey, surgeon, of Dorset-
street, Portman-square, to dissect, and he kindly permitted me
to make a drawing from the limb. It appeared, upon view of the
thigh, that the limb had been broken just above the knee-joint,
and that the shaft of the bone projected as far as the skin, just
above the patella : the union was firm, but the magnitude of the
bone was exceedingly increased. When the integuments were
removed, the end of the superior portion of the shaft of the bone
was found to have pierced the rectus muscle, through which it
still continued to project (see plate); and behind this projecting
portion of bone the rectus muscle was situated, which passed to
the patella. The patella, on the attempt to draw it up, was
stopped by the projection of the fracture, so that its movement
upwards was exceedingly limited. The condyles of the os femoris,
and the lower portion of the bone, had been drawn by the action
of the muscles behind the end of the fracture of the upper portion,
and had united by a very firm callus to the body of the bone.
This union had necessarily produced a great diminution in the
power of extending the limb ; for the rectus muscle was really
hooked down by the fractured extremity of the bone : but even if
the bone had not pierced the muscle, still the elevation of the
patella would have been prevented, by its being drawn against
the fractured end of the thigh-bone in the contraction of the
muscle. It appears, then, in the treatment of this case, that a
most firm and continued extension must be supported to prevent
FRACTURES OF THE KNEE. 219
the retraction which will otherwise ensue ; but it will be seen by
the two following cases, that this defective union is, with great
difficulty prevented ; and that the complete flexion of the limb
afterwards, was not in either instance accomplished.
COMPOUND FRACTURE JUST ABOVE THE
CONDYLES OF THE OS FEMORIS.
CASE.
Mr. Kidd, who weighed fifteen stone, fell on the 9th of Novem- case.
ber, 1819, from the height of twenty-one feet upon his feet, and
broke his thigh-bone just above the knee by the severity of the
concussion. The fracture was situated immediately above the
condyles, and the broken extremity of the shaft of the bone
appeared through the integuments and rectus muscle, just above
the patella. He was immediately carried home, and I saw him,
with Mr. Phillips, surgeon to the King's household, a short time
after the accident. We agreed that the projecting extremity of
the thigh-bone should be immediately sawn ofl", and that the edges
of the wound should be approximated so as to render the fracture
simple ; and this was immediately done. The limb was placed
upon the double inclined plane. The wound healed without diffi-
culty, and our first object was thus accomplished. On the 30th
of November, splints were applied, in order to press the bones
firmly together. On December 23rd, the leg was straightened.
F F 2
220 FRACTURES OF THE KNEE.
and the inclined plane was lowered, so as to brin^ the limb
gradually into a straight position. On February the 2nd, he
sat up in bed. On the 7th of February, the knee having been
moved, the fractured bones appeared to separate, and on the 14th,
it was clearly ascertained that the bone was not united. On the
16th, a leathern bandage with many straps was tightly buckled
around the knee. Having previously tried the position upon his
side, which only led to a greater separation of the bone, he was
again placed upon his back. On the 3rd of May, the bone was
found to be united, and on the 12th, the leathern bandage was
removed, and the limb placed on a pillow. On the 10th of July,
he moved from one side of the bed to the other with difficulty, and
on the 16th, was placed on another bed, which was obliged to be
adjusted to the exact level with the other, before his removal
could be accomplished. On July the 19th, he was removed from
London to Kensington on a litter. On the 8th of August, the
thigh was fomented, in order to remove the excessive bulk it had
acquired, and to diminish its hardness ; but the fomentation was
discontinued on the 14th, because it was found to increase the
swelling. On the loth, the leg was bathed with the liquor
plumbi subacetatis dilutus, and spirits of wine: the skin having
been ulcerated from the time that the bandage was buckled tight
around the knee. On October the 24th, the leg was placed in a
gout cradle. On the 16th, he was on a sofa for two hours, but
on the 28th, was obliged to keep in bed, because irritation and
swelling had been produced by moving on the two preceding
days. On November the 3rd, he was wheeled into another room
I
FRACTURES OF THE KNEE. 221
on a chair. On January the 29th, 1822, he was, for the first
time, on crutches ; and on February the 24th, he first walked out
of doors.
His present state, March 1822, is as follows : The hone above
the knee is excessively enlarged; the patella is fixed below the
broken extremity of the shaft of the bone, the point of which
adheres to the skin.
Mr. Kidd possessed a very fine constitution, for his pulse after
the accident never exceeded 63; and although the rectus muscle
was penetrated by the bone, he never complained of any spasmodic
contraction of the limb.
SIMPLE FRACTURE ABOVE THE CONDYLES OF
THE OS FEMORIS.
For the following history I am indebted to Mr. Welbank, Jun.,
who attended the case with me.
CASE.
Mr. , of middle age, muscular and tall, was driving on the
morning of July 20th, 1821, in the neighbourhood of Leicester-
fields, and was thrown forward out of his gig, over the horse,
which had fallen. It is probable that the external condyle of the
right femur received the force and weight of his descent upon
the pavement. He was brought from Leicester-fields to Chan-
cery-lane in a coach, with his legs out of the door, no surgical
222 FRACTURES OF THE KNEE.
assistance having been yet procured. When first seen by his surgi-
cal attendant he was lying upon his back on the bed, with the right
leg bent and lying across the middle of the left leg at an angle.
There was an appearance resembling the lateral dislocation of the
knee, from a deep hollow, visible on the external side of the joint,
in the situation of the external condyles ; above this hollow, close
to the joint, and on its external or fibular side, an abrupt and
sharp projection of bone was distinctly observable. Slight exten-
sion replaced the parts, and it now appeared that the thigh had,
previously to the reduction, been bent inwards over the left, upon
an oblique fracture, situated close to the patella. The patella
itself was very obscurely felt through a circumscribed efifusion in
front of the joint. Just above the situation of its upper edge
might still be traced the ridge of the fracture, a slight groove
intervening: the appearance, indeed, at this and later periods of
the accident might have been mistaken, on superficial examina-
tion, for the transverse fracture of the patella. Flexion produced
great projection of the upper part of the femur, and extension
readily restored the natural appearance, except in the swelling on
the front of the patella. The crepitus was very indistinct, if at
all observable.
Little more was done during the first week than steadying the
joint in the extended position with short splints, and subduing the
inflammation of the capsule which supervened. After this period,
a long splint was applied from the trochanter major to the outside
of the foot, and an opposing short splint from the middle of the
femur to the middle of the inside of the leg, and firmly confined
by tapes and buckles. The whole limb was supported upon an
FRACTURES OF THE KNEE. 223
inclined plane, and flexion cautiously obviated. To prevent motion
of the pelvis the stools were removed in napkins. The posture
was not, however, steadily maintained ; and it was frequently
found that the upper point of bone varied in its degree of projec-
tion, and at different times, more or less, encroached on the situa-
tion of the upper edg'e of the patella. To remedy this, slight
permanent extension, with weights appended to the foot, was
adopted with advantage ; though I believe that the position was
by no means rigorously maintained, for I have since understood
that the patient, not unfrequently, even had his back washed. The
ridge of the upper portion of the femur appeared, however, to
project so slightly, that it was deemed better to ensure union, than
to add to the frequency of disturbance, by being too solicitous
of exact apposition.
About September the 7th, the bone was thought sufficiently
united, but flexion was neither attempted by the surgeon, nor
permitted to the patient. On September the 10th, the patient was
removed to Eastbury, Hertfordshire, in a litter-carriage, as his
health was suffering : the limb being steadied with splints, and the
position resumed, during the journey. In removing from one bed
to another, and in other alterations of posture, it was obvious that
flexion produced a greater appearance of projection of the femur
than had been anticipated. This might be referred to the drawing
down, or rather sinking of the patella in flexion ; and, indeed, it
could to appearance be nearly remedied by elevating the leg upon
the thigh, as in extension. Under these circumstances, however,
rest in the extended posture was again adopted for a fortnight.
About September 25th, a second examination decided the necessity
224 FRACTURES OF THE KNEE.
for further rest, as the increase of projection, on flexion of the
knee, and a slight lateral motion, induced a belief of infirm union.
It is worthy of mention, that the immediate vicinity of the joint,
the mobility of the patella, and the general thickening, rendered
all examinations of extreme difficulty and uncertainty. A circu-
lar belt was tightly girded upon the situation of the injury, with a
view of compressing the fracture, and maintaining the parts in
firm apposition. October 16th, the union was considered complete,
and the patient allowed to get up. On November 1st, he resumed
his professional duties as an advocate. For a considerable period
he suffered pain and swelling of the limb, but has gradually and
sloAvly improved.
May, 1822. At this date he can walk about his room without
assistance either of crutch or stick. He has little power of flexion
at the knee-joint. The joint is, however, apparently moveable to
a certain extent beneath the patella, which bone is fixed beneath
the projecting edge of the upper portion of the femur, which
evidently overlaps and displaces it. There is visible shortening
of the limb, and the contour of the thigh is somewhat bowed
outwards.
J. Welbank, Jun.
Chancery Lane.
To obviate the evils which are produced by this formidable
accident, I have had an apparatus constructed to preserve the
thigh in a constant state of extension. (See plate.) The leg is
to be first bent, to draw the rectus muscle over the broken
extremity of the bone, and then the apparatus is to be applied,
FRACTURES OF THE KNEE. 225
and the limb to be preserved in a constant state of extension in
the straight position.
FRACTURE OF THE HEAD OF THE TIBIA.
The head of the tibia is sometimes obHquely broken ; and if it Ja"t^"gg
be fractured into the knee-joint, the treatment which it requires is *^^*'^'^'°^''
fractures of
the tibia
the joint
similar to that which is necessary in the oblique fracture of the
condyle of the os femoris ; that is, first, to maintain the straight
position of the limb, because the femur preserves the proper
adaptation of the fractured tibia by serving as a splint to its
upper portion, and keeping the articular surfaces in apposition.
Secondly, a roller to press one part of the broken surface against
the other. Thirdly, a splint of pasteboard to assist in the
preservation of that pressure. And fourthly, early passive motion
to prevent anchylosis.
But if the fracture of the tibia be oblique, yet not into the Fracture
just below
joint, then it is best to place the limb upon the double inclined 'he joint,
plane ; for the cause of deformity being the elevation of the lower
portion of the tibia, which is drawn up on the side of the knee-
joint, as the fracture is in the inner or outer side of the tibia, the
weight of the leg keeps the limb constantly extended as it hangs
over the angle of the inclined plane, and thus the bone is brought
into as accurate apposition as the nature of the fracture permits.
G G
226 FRACTURES OF THE KNEE.
DISLOCATIONS OF THE HEAD OF THE FI:BULA.
The fibula joins the tibia, three quarters of an inch below the
articulation of the knee. Its head is inclosed in a capsular Hga-
unionwith ment, which unites it to the tibia, to which it is also ioined
the tibia, ^ *f
through the greater part of its length by the interosseous
ligament.
Produced by This bouc is Hablc to dislocation, both from violence and from
violence or
relaxation, rclaxation. I have only seen one case of it from violence, and
in that instance it was connected with the compound fracture
of the tibia.
Briggs, of whose dislocation of the tibia I have given an
account, had, at the upper part of the other leg, a compound
fracture of the tibia, and dislocation of the head of the fibula.
An attempt was made to save the limb, but the constitutional
irritation ran so high, that amputation was obliged to be per-
formed ; which was done by my colleague, Mr. Lucas, and the
man was restored to health.
Dislocations of the head of the fibula from relaxation, are
more frequent than those which occur from violence ; the head
of the bone, in these cases, is thrown backwards, and is easily
brought into its natural connexion with the tibia, but it directly
again slips from its position. This state produces a considerable
degree of weakness and fatigue in walking, and the person suflfers
much from exercise. As in these cases there is a superabun-
dant secretion of synovia, and a distention of ligament, repeated
FRACTURES OF THE KNEE. 227
blistering' is required to promote absorption ; and afterwards a strap
is to be buckled around the upper part of the leg, to bind the
bone firmly in its natural situation ; a cushion may be added
behind the head of the bone, to give it support, and at least
prevent the increase of the malady.
G G 2
DISLOCATIONS OF THE ANCLE- JOINT.
Structure of The bones which enter into the composition of the ancle-ioint
the joint. '■ ''
are the tibia, fibula, and astragalus. The tibia forms an articu-
lating surface at its lower part, which rests upon the astragalus ;
and there is a projection on the inner side of the lower portion of
this bone, which forms the malleolus internus, and this part is
Bone. articulated with the side of the astragalus. The fibula projects
beyond the tibia at the outer ancle, and forms there the malleolus
externus, which has also an articulating surface for the astragalus.
The astragalus, which is the superior tarsal bone, rises between
the malleoli and the lower part of the tibia, and moves upon it
principally in flexion and extension of the foot.
Thus nature has strongly protected this part of the body, by the
deep socket formed by the two bones of the leg, and by the ball
of the astragalus which is received between them.
Capsular A capsular ligament, secreting synovia on its internal surface,
igamen. j^'j^g ^|^g ^'l^jg^ ^^^^ fibula to the astragalus. A strong ligament
unites the tibia to the fibula, but without any intervening articular
DISLOCATIONS OF THE ANCLE-JOINT. 229
cavity, as the ligament proceeds directly from one surface of bone
and is received into the other.
The peculiar ligaments joining the tibia and fibula to the tarsus, Peculiar
r ^ 1 ' ^ ^• I'l in i •!• i ligaments,
consist oi a deltoid ligament, which proceeds from the tibia to the
astragalus, os calcis. and os naviculare. The fibula is united at
its lower end by three excessively strong ligaments ; one anteriorly
from the malleolus externus to the astragalus, one inferiorly to
the OS calcis, and the third to the astragalus posteriorly ; and it is
the strong union of this bone which leads to its being more
frequently fractured than dislocated ; and even when the tibia is
luxated the fibula is fractured in two of the species of dislocation
of the ancle, and generally in all ; but when the tibia is thrown
outwards I have known the fibula escape a fracture.
I have seen the tibia dislocated at the ancle in three diff*erent
directions : inwards, forwards, and outwards ; and a fourth species Direct.onsof
dislocations.
of dislocation is said sometimes to occur, viz., backwards : the
foot has also been known to be thrown upwards between the tibia
and fibula, by the giving way of the ligament which unites these
bones ; but this accident is only an aggravated state of the
internal dislocation.
SIMPLE DISLOCATION OF THE TIBIA INWARDS.
This is the most frequent of the dislocations of the ancle ; the Dislocation
tibia in this accident has its internal malleolus thrown inwards, """"^ '"
230 DISLOCATIONS OF THE ANCLE-JOINT.
which SO forcibly projects against the integuments as to threaten
Symptoms, their bursting. The foot is thrown outwards, and its inner edge
rests upon the ground. It rotates easily on its axis. There is
considerable depression above the outer ancle, much pain, some
crepitus, often at three inches from the lower joints of the fibula
upwards, facility of lateral motion of the foot, and considerable
tumefaction.
Dissection. Upou disscction, the internal appearances are as follows : The
end of the tibia rests upon the inner side of the astragalus, instead
of resting on its upper articulatory surface ; and if the accident
has been caused by jumping from a considerable height, the
lower end of the tibia, where it is connected to the fibula by
ligament, is split off, and remains connected with the fibula, which
is also broken from two to three inches above the joint, and the
broken end of the fibula is carried down upon the astragalus,
occupying the natural situation of the tibia; the malleolus externus
of the fibula remains in its natural situation, with two inches of
the fibula and the split portion of the tibia ; the capsular ligament
attached to the fibula at the malleolus externus, and the three
strong fibular tarsal ligaments, remain uninjured.
This accident generally happens in jumping from a consi-
derable height, or in running violently with the toe turned out-
wards, when the foot being suddenly checked in its motion while
the body is carried forwards upon the foot, the ligaments on the
inner side of the ancle give way; it may also be caused by a
fall on that side, when the foot is fixed.
To distinguish a fracture of the fibula, the hand must grasp
DISLOCATIONS OF THE ANCLE-JOINT. 231
the leg just above the ancle, and then the foot must be freely
rotated ; Avhen, the motion of the foot being* communicated to the
fibula, pain will be felt, and a crepitus perceived.
For the reduction of this dislocation, which cannot be too soon Mode of
reduction.
accomplished, the patient is to be placed upon a mattress properly
prepared, and is to rest on the side on which the injury has been
sustained ; the surgeon is then to bend the leg at right angles
with the thigh, so as to relax the gastrocnemii muscles as much
as possible ; and an assistant grasping the foot, must gradually
draw it in a line with the leg. The surgeon then fixes the thigh
and presses the tibia downwards, thus forcing it upon the articu-
lating surface of the astragalus. Great force is required if the
limb be placed in the extended position, from the resistance of the
gastrocnemii ; and it is pleasing to observe, after most violent
attempts by others, a well-informed surgeon gently bend the limb,
and, under a comparatively slight extension, return the parts to
their natural situation.
When the limb has been reduced it is still to remain upon its Treatment,
outer side in the bent position, with the foot well supported; a
many-tailed bandage is to be placed over the part to prevent it
from slipping, and this is to be kept wet with an evaporating
lotion. Two splints are then to be applied ; and each is to have a
foot-piece, to give support to the foot, prevent its eversion, and
preserve it at right angles with the leg. If much inflammation
succeeds, leeches are to be applied to the parts, and the consti-
tution will require relief by taking blood from the arm, and by
attention to the bowels; but I shall say no more on this subject
until I describe compound dislocation of this joint. A person who
232
DISLOCATIONS OF THE ANCLE-JOINT.
has sustained this accident may he removed from his hed in five
or six weeks, long straps of plaster being passed around the joint
to keep the parts together, and he may be suffered to walk on
crutches ; but from ten to twelve weeks will elapse before he has
the perfect motion of the foot ; and much friction and passive
motion will be required after the eighth week to restore the
natural motion of the joint.
SIMPLE DISLOCATION OF THE TIBIA FORWARDS.
Symptoms. lu this accidciit the foot appears much shortened and fixed, the
heel is proportionably lengthened and firmly fixed, and the toes
are pointed downwards. The lower extremity of the tibia forms a
hard projection upon the upper part of the middle of the tarsus,
under the projected tendons, and a depression is situated before the
Dissection, tcudou Achillis. Upon dissection the tibia is found to rest upon
the upper surface of the os naviculare and os cuneiforme internum;
quitting all the articulatory surface of the astragalus, excepting a
small portion on its fore part, against which the tibia is applied.
The fibula is broken, and its fractured end adv^ances with the
tibia, and is placed by its side : its malleolus externus remains in
its natural situation, but the fibula is broken about three inches
above it. The capsular ligament is torn through on its fore part.
The deltoid ligament is only partially lacerated, and the three
Cause ligaments of the fibula remain unbroken. This accident arises
from a fall of the body backwards whilst the foot is confined, or
DISLOCATIONS OF THE ANCLE-JOINT. 233
from that of a person jumping" from a carriage in rapid motion
with the toe pointed forwards.
The treatment consists in attending to the following rules : The Reduction.
patient should be placed in bed on his back ; one assistant grasps
the thigh at its lower part and draws it towards the body, another
pulls the foot in a line a little before the axis of the leg, and the
surgeon pushes the tibia back to bring it into its place. The Treatment.
same principles are held in view in this mode of reduction as in
the former, with respect to the relaxation of the muscles. A many-
tailed bandage, dipped in an evaporating lotion, must be lightly
applied. The local and constitutional treatment is the same as in
the dislocation inwards.
As to position, it is best to keep the patient with the heel rest-
ing on a pillow, and to have a splint, properly guarded, on each
side of the leg, having foot-pieces to keep the foot well supported
at right angles with the leg, so as to prevent the muscles again
drawing it from its place. As in five weeks the fibula will be
united, there will then be no danger in taking the patient from
his bed, and gentle passive motion may be begun.
The application of a long splint on each side, with a foot-piece
to each splint, and this padded in such a manner as to give the
foot a direction inwards, outwards, or at right angles, according
to the direction of the dislocation, answers better than any other
mode of securing it. (See plate.) When this is applied, the
foot cannot escape from the situation in which the surgeon has
placed it.
M. Dupuytreer, of the Hotel Dieu, who is a very scientific as
well as an excellent practical surgeon, has recommended a single
H H
234 DISLOCATIONS OF THE ANCLE-JOINT.
splint, \vell ciishio lied, along the outer or inner part of the leg-,
according to the direction of the dislocation, and fastened to the
leg' and foot by bandages. (See a plate in Joluisons Medico-
Chiriirgical Review.^
PARTIAL DISLOCATION OF THE TIBIA FORWARDS.
This bone is sometimes partially luxated forwards, so as to rest
Symptoms, j^^jf Qj^ ^jjg (^g naviculare, and half on the astragalus. The fibula
in this accident is broken ; the foot appears but little shortened,
nor is there any considerable projection of the heel. The fol-
lowing are the signs of this accident : the foot is pointed
downwards, and a difficulty is experienced in the attempt to put it
flat on the ground ; the heel is drawn up, and the foot is in a
great degree immoveable.
Case. The first case of this kind which I saw was in a very stout
lady, who resided at Stoke Newington, and had by a fall, as she
said, sprained her ancle. When I examined the limb I found the
foot immoveably fixed, pointed downwards, and attended with
great pain just above the ancle. I attempted to draw the foot
forwards and bend it, but could not succeed. Some years after-
wards I saw this lady at Bishop Stortford, walking upon crutches;
her toe was pointed, and she was unable to bring any other part
of the foot to the ground ; the degree of distortion was less than
that which occurs in the complete luxation of the bone forwards ;
but all tension having now been subdued the nature of the injury
DISLOCATIONS OF THE ANCLE- JO INT. 235
was more evident, though I should not have known it decidedly,
without an examination of a foot shewn to me by my friend and
late apprentice, Mr. Tyrrell, who was so kind as to give me the
parts which were taken from a subject dissected at Guy's Hospital.
The articular surface of the lower part of the tibia was divided Dissection.
into two ; the anterior part was seated upon the os naviculare,
the posterior upon the astragalus; these two articulatory surfaces,
formed at the lower extremity of the bone, had been rendered
smooth by friction. The fibula was found fractured. (See plate.)
The result of this dislocation clearly proves the necessity which
exists in these accidents, however slight they may at first sight
appear, of not resting satisfied until the foot be returned into its
natural position, and restored to its motion ; for, if neglected in
the commencement, severe inflammation and tension will prevent
even a forcible extension from being afterwards useful ; and, if
still longer neglected, the changes in the state of the muscles, and
the union of the fractured fibula, will preclude the possibility of a
reduction, even under the most violent attempts. The mode of
reduction and aftertreatment will in no respect difiier from that
required in the perfect dislocation of the bone forwards, either in
regard to the relaxation of the muscles, the bandages, or the local
and constitutional treatment.
SIMPLE DISLOCATION OF THE TIBIA OUTWARDS.
This luxation is the most dangerous of the three ; for it is
produced by greater violence, is attended with more contusion of
H H 2
236 DISLOCATIONS OF THE ANCLE-JOINT.
the integuments, more laceration of ligament, and greater injury
Symptoms, to the boiie. The foot is thrown inwards, and its outer edge rests
upon the ground. The malleolus externus projects the integu-
ments of the ancle very much outwards, and forms so decided a
prominence that the nature of the injury cannot be mistaken.
The foot and toes are pointed downwards.
Dissection. ^^^ ^hc disscctiou of this accident, it is found that the malleolus
internus of the tibia is obliquely fractured, and separated from
the shaft of the bone. The fractured portion sometimes consists
only of the malleolus, at others the fracture passes obliquely
through the articular surface of the tibia, which is thrown forwards
and outwards upon the astragalus, before the malleolus externus.
The astragalus is sometimes fractured, and the lower extremity of
the fibula is broken into several splinters. The deltoid ligament
remains unbroken, but the capsular ligament is torn on its outer
part. The three fibular tarsal ligaments remain whole in most
cases, but when the fibula is not broken they are ruptured. None
of the tendons are lacerated, and internal haemorrhages scarcely
ever occur to any extent, as the large arteries generally escape
injury. This accident happens either by the passage of a carriage-
wheel over the leg, or by a distortion of the foot in jumping or
falling.
Reduction. Thc uiodc of rcduction consists, in placing the patient upon his
back, in bending the thigh at right angles with the body, and the
leg at right angles with the thigh ; the thigh is then grasped
under the ham by one assistant, and the foot by another; and
thus an extension is made in the axis of the leg, whilst the sur-
geon presses the tibia inwards towards the astragalus. The limb.
I
DISLOCATIONS OF THE ANCLE-JOINT. 237
in the simple dislocation, is to be laid upon its outer side, resting
upon splints, with foot-pieces; and a pad is to be placed upon the
fibula, just above the outer ancle, and extending a few inches
upwards, so as in some measure to raise that portion of the leg
and support it ; and to prevent the slipping of the tibia and fibula
from the astragalus, as well as to lessen the pressure of the
malleolus externus upon the integuments where they have sus-
tained injury.
The local and general treatment will be the same as in the Treatment,
former cases, although more depletion is required, as greater
inflammation succeeds ; the greatest care is necessary to prevent
the foot from being twisted inwards, or pointed downwards, as
either position prevents the limb from being afterwards useful ;
and this precaution is effected by having two splints, with a foot-
piece to each, padded and applied to the ancle on the outer side of
the leg. Passive motion should be given to the joint in six weeks
after the accident, when the patient may rise from his bed, and be
allowed to walk upon crutches, unless impeded by great swelling
of the ancle. In the generality of these cases, from ten to twelve
weeks elapse before the cure is complete.
COMPOUND DISLOCATION OF THE ANCLE-JOINT.
These accidents take place in the same direction as the simple
dislocations, and the bones and ligaments suffer in the same man-
ner as in those dislocations. The difference, therefore, in these
238 DISLOCATIONS OF THE ANCLE-JOINT.
openinginto casBS is, that the joint is laid open by a wound in the integuments
and ligaments, opposite to the laceration of the skin, by which
the synovia escapes, and through which the ends of the bone
protrude ; this opening in the integuments is generally occasioned
by the bone, but sometimes by the pressure of some uneven sur-
face on which the limb may have been thrown.
The bones being replaced by the means which are employed
in the simple dislocation, the effects of this accident upon the
parts composing the joint are as follows : The synovia, as I have
stated, escapes by a large wound through the lacerated ligament,
Locaieflects. aiid ill a fcw hours inflammation begins ; and when an additional
quantity of blood is first determined to the part, an abundant
secretion issues from this membrane, and is discharged through
the wound; the ligaments participate in the inflammation, as well
as the extremities of the bones which enter into the composition of
the joint. The inflammation of the internal secreting- surface of
the ligament, in about five days, proceeds to suppuration ; at first
but little matter is discharged, but it continues increasing until it
becomes very abundant, and the lacerated parts of the ligaments
and periosteum also secrete matter. Under this process of sup-
puration, the cartilages become partially or Avholly absorbed, but
in general only partially ; for the ulceration of the cartilage is a
very slow process, attended with severe constitutional irritation,
and often lays the foundation for exfoliation of the extremities of
the bones. When the cartilages are absorbed, granulations arise
from the surface of the bones and from the inner side of the
ligament, and these inosculate and fill the cavity between the
extremities of the bones. Sometimes we find after accidents to
DISLOCATIONS OF THE ANCLE-JOINT, 239
joints, that the adhesive process occurs at one part, and that the
cartilage is not absorbed ; whilst g-ranulations are formed at
others, where tlie cartilage was removed by ulceration ; and I
have seen, after inflammation in joints, the cartilages remain, and
their surfaces adhere.
Neither this inosculation of granulations, nor the process of
adhesion, leads to permanent anchylosis ; for if passive motion
be begun as soon as the parts, from cessation of pain and
inflammation, will permit, motion will be restored, not always
entirely, but with very little diminution ; and the other joints of
the tarsus will acquire such an extent of motion as to render the
deficiency in the mobility of the ancle-joint but little apparent.
The aperture in the ligament is filled by granulations ; and with
respect to the extremities of the bone, when they are joined by
ossific union, this junction is effected by the deposite of cartilage,
and by a secretion of phosphate of lime, in the usual manner in
which bones are formed and repaired.
Thus, then, the compound dislocation of the ancle leads to
inflammation over a very extensive secreting surface ; it produces
an extended suppuration over the lining of the joint, which
occasions much constitutional derangement ; and, further, it be-
comes the source of an ulcerative process, more or less extensive
according to the treatment pursued ; by which the cartilage is
partly or wholly removed, and by which an irritative fever is
supported for a great length of time ; and the ulceration some-
times extends over the extremities of the dislocated bones, and
leads to a greatly augmented constitutional irritation, and pro-
tracted disease from exfoliation.
240 DISLOCATIONS OF THE ANCLE-JOINT.
These local effects are accompanied by the common symptoms
of constitutional excitement. In two or three days from the
accident, or sometimes as early as twenty-four hours, the patient
complains of pain in his back and in his head, shewing the
influence of the accident on the brain and spinal marrow. The
tongue is furred ; white, if the irritation be slight ; yellow, if
greater; and brown, almost to blackness, if it be considerable;
the stomach is disordered ; there is loss of appetite, nausea, and
sometimes vomiting ; secretion ceases in the intestines and in the
glands connected with them, as the liver, &c. ; costiveness is
therefore an attendant symptom. The skin has its secretion
stopped ; it becomes hot and dry ; the kidneys also have their
secretion diminished ; the urine is high coloured, and small in
quantity. The heart beats more quickly and the pulse becomes
hard, which is the pulse of constitutional irritation from local
inflammation, and in great degrees of this excitement, it becomes
irregular and intermittent ; the respiration is quicker, in sympathy
with the quicker circulation ; the nervous system becomes addition-
ally afl'ected, in high degrees of local irritation ; restlessness,
watchfulness, delirium, subsultus tendinum, and sometimes tetanus
occur. These are the usual eflects of local irritation upon the
constitution, occurring in different degrees, according to the
violence of the injury, the irritability of the system, and the
powers of restoration.
Cause of the Thc causcs of the violence of these symptoms are, the wound
symptoms. ^ ^ . ,.. , (Y» • 1 n •
which is made into the jomt, and the great efforts required lor its
repair : for when there is no wound, and the process of adhesion
can unite the part, little local inflammation or constitutional
DISLOCATIONS OF THE ANCLE-JOINT. 241
irritation can occur ; and if this be the cause of the violence of the
symptoms, the principle in the treatment of this accident is easily Principle of
comprehended ; it consists in closing the wound as completely
as possible, to assist nature in the adhesive process by which the
wound is to be closed, and to render suppuration and granulation
less necessary for the union of the opened joint.
The first question which arises upon this subject is the following-:
Is amputation o-eneralhi necessary in compound dislocations of the isamputa-
i o «/ t/ J «/ tion requir-
ancle? My answer is, certainly not. Thirty years ago it was ""^^
the practice to amputate limbs for this accident ; and the operation
was then thought absolutely necessary for the preservation of life,
by some of our best surgeons ; but so many limbs have been
saved of late years, indeed, I may say, so great a majority of
these cases exists, that such advice would now be considered not
only injudicious, but cruel. It is far from being my intention to
state that amputation is never required ; I have only to observe,
that in the greater number of these accidents the operation is
unnecessary.
But before I give the proofs of what I have advanced, I shall
state the mode of treatment which is to be pursued in these cases.
When the surgeon examines the limb, he finds a wound of Treatment.
greater or less extent, according to the degree of the injury.
The extremity of the tibia projects if the dislocation of the tibia be
inwards ; and the tibia and fibula are protruded, if the dislocation
of the former be at the outer ancle. The ends of the bones are
often covered with dirt from their having reached the ground.
The foot is loosely hanging on the inner or outer side of the leg',
according to the direction of the dislocation. Sometimes, though
I I
242 DISLOCATIONS OF THE ANCLE-JOINT.
^rteiy verv rarelv, a large artery will be divided; and it is surprising
divided.
that the posterior tibial artery so generally escapes laceration ;
the anterior tibial being the only vessel I have known to be torn.
The arrest of haemorrhage is the first object; and for this purpose,
if the anterior tibial artery be wounded, it must be secured by
ligature. The extremity of the bone is to be washed with warm
water, as the least extraneous matter admitted into the joint will
produce and support a suppurative process ; and the utmost care
should be taken to remove every portion of it adhering to the end
of the bone.
Loose pieces If the bouc bc shattcrcd, the fina^er is to be passed into the
of bone. '-' ^
joint, and the detached pieces are to be removed ; but this is to be
done in the most gentle manner possible, so as not to occasion
unnecessary irritation. If the wound be so small as to admit the
finger with difficulty, and if small pieces of bone can be felt, the
integuments should be divided with a scalpel, to allow of such
portions being removed without violence ; the incision should be
so made as to leave the joint with as much covering of integument
Integuments as possiblc, Thc iutcguments are sometimes nipped into the
joint by the projecting bone ; and then it cannot be reduced
without making an incision, to allow the skin to be drawn from
under the bone; and when the edges of the incised wound are
afterwards brought together, no additional evil arises from the
extension of the Avound.
Reduction. The modc of reducing the bone is, in other respects, similar to
that which I have already described when speaking of simple
dislocation ; by bending the leg upon the thigh, so as to relax the
muscles before the extension is made. When the bone has been
DISLOCATIONS OF THE ANCLE-JOINT. 243
reduced, a piece of lint is to be dipped in the patient's blood, and
applied wet over the wound, upon which the blood coagulates, and
forms the most natural, and, as far as I have seen, the best
covering' for the wound. A many-tailed bandage is then applied,
the portions of which should not be sewn together, but passed
under the leg", so that any one piece may be removed when it
becomes stiff; and by fixing another to its end, the application
may always be renewed without any disturbance to the limb : this
bandage is to be kept constantly wet with spirits of wine and
water. A holloAv splint, with a foot-piece at right angles, is to be
applied on the outer side of the leg, in the dislocation inwards,
and the leg is to rest upon its outer side : but in the dislocation
outwards, it is best to keep the limb upon the heel, with a splint
and foot-piece both upon the outer and the inner side ; and an
aperture in the splint opposite to the wound.
In each dislocation the patient's knee is to be slightly bent, to
relax the gastrocnemius muscle. The foot must be carefully
prevented from being pointed ; great care being taken to preserve
it at right angles with the leg, otherwise the limb will be useless
when the wound is healed. The patient is to be placed on a
mattress, and a pillow is to reach from half way above the knee ment.
to beyond the foot, and another is to be rolled under the hip, to
support the upper part of the thigh-bone.
Blood-letting must be adopted, or not, according to the powers
of the constitution ; as it is necessary to bear in mind that the
patient has a great trial of his powers to undergo, and will require
throughout the process of restoration, all the support which his
strength can receive. Purgatives must also be used with the Purging
I I 2
Constitu-
tioual treat-
Blood-let-
ting-.
244 dislocatiojns of the ancle-joint.
utmost caution, for there cannot be a worse practice, when a limb
has been placed in a good position, and adhesion is proceeding,
than to disturb the processes of nature by the frequent changes of
position which purges produce ; and I am quite sure, that in cases
of compound fracture, I have seen patients destroyed by their
frequent administration. That which is to be done by bleeding,
and emptying the bowels, should be effected as soon as is possible
after the accident, before the adhesive inflammation arises ; after
which the liquor ammoniae acetatis, and tinctura opii, form the
patient's best medicine, with a slight aperient at intervals.
Secondary If thc oaticut complaiu of considerable pain in the part, in four
treatment. 11 11'
or five days, the bandage may be raised to examine the wound ;
and if there be much inflammation, a corner of the lint should be
lifted from the wound, to give vent to any matter which may be
formed ; but this ought to be done with great circumspection, as
there is a danger of disturbing the adhesive process, if that be
proceeding without suppuration. By this local treatment, it will
every now and then happen that the wound will be closed by
adhesion, but if in a few days it be not, and if suppuration take
place, the matter should have an opportunity of escaping ; and the
lint being removed, simple dressing should be applied. After a
week or ten days, if there be suppuration with much surrounding
inflammation, poultices should be applied upon the wound, leeches
in its neighbourhood, and upon the limb at a distance, and the
evaporating lotion should be still employed ; but as soon as the
inflammation is lessened, the poultices should be discontinued, as
they encourage too much secretion, and relax the blood vessels of
the part, so as to prevent the restorative process.
DISLOCATIONS OF THE ANCLE-JOINT. 245
If the cure proceeds favourably, in a few weeks the wound is Result.
healed with little suppuration ; if less favourably, a copious sup-
puration takes place, the wound is longer in healing, and exfolia-
tion of portions of the extremity of the bone still further retards
the cure. The motion of the joint is not always lost ; it is some-
times in a great degree restored : but this depends upon the
greater or less extent of suppuration or ulceration. Under the
most favourable circumstances, three months generally elapse
before the patient can walk with crutches ; in many cases, how-
ever, a greater length of time is required : he bears upon the foot
at different periods of time, according to the degree of injury
sustained, as in compound fracture, when adhesion is not at first
produced : in compound dislocations, of course, the patient is
longer in recovering.
I shall nov/ proceed to state the cases which have induced me to
say that amputation, as a general rule, is improper in these cases.
The circumstances Avhich led me to doubt the soundness of the
opinion which recommended an indiscriminate amputation of these
injuries, were these :
CASE I.
I was, many years since, going into the country with a friend of
mine, and we met with a surgeon in our journey who put this
question : " What do you do in compound dislocations of the
ancle-joint.^" I do not recollect the reply, but he proceeded to
say, " t have had a case of compound dislocation of the ancle-
joint under my care, in which I told the patient he must lose his
limb : not approving this advice, his friends sent for another
246 DISLOCATIONS OF THE ANCLE-JOINT.
surgeon, who said he thought he could save it ; the patient placed
himself under his care, and the man is recovering."
About thirty years ago, I received from Mr. Lynn, of Wood-
bridge, now Dr. Lynn, of Bury St. Edmunds, the astragalus of a
man broken into two pieces, which he had taken from a dislocated
ancle-joint. His letter is as follows :
CASE IL
Dear Sir,
J. York, aged thirty-two years, being pursued by some
bailiffs, jumped from the height of several feet to avoid them.
The tibia and a part of the astragalus protruded at the inner
ancle. I immediately returned the parts into their natural situ-
ation. Suppuration ensued ; and in five weeks a portion of the
astragalus separated, and another piece a week afterwards, which,
when joined, formed the ball of that bone. In three months,
the joint was filled with granulations ; it soon afterwards healed,
and the man recovered with a good use of the limb.
Your's, &c.
James Lynn.
1 attended a compound dislocation of the ancle-joint, in the year
1797, with Mr. Battley, who then practised as a surgeon in St.
Paul's Church-yard, and is now an eminent chemist and druggist
in Fore Street. An account of this case I shall give in the words
of Mr. Battley.
DISLOCATIONS OF THE ANCLE-JOINT. 247
CASE III. ^
In the month of September, 1707, a gentleman, lodging in
Duke-street, Smithfield, in a fit of insanity, threw himself from Accompa.
a two-pair of stairs Avindow into the street, his feet first reaching insanUy.
the ground. He rose without help, knocked violently at the
outer door of the house, and ascended the stairs without the least
assistance ; bolted the door after him, and got into bed. He
refused to open the door, and it was obliged to be forced. A
neighbouring surgeon was sent for, who, on viewing the case,
proposed an immediate amputation, which was not acceded to
by his friends ; but Mr. Cooper and myself were requested tp
take charge of the case. On examination, there was found a
compound dislocation of the ancle-joint. The tibia was thrown
on the inner side of the foot ; and when the finger was passed
into the wound, the astragalus was discovered to be shattered
into a number of pieces. The loose and unconnected portions of
bone were removed, and the tibia was replaced ; after which, lint,
dipped in the oozing blood, was wrapped around the lacerated
parts, and the limb was placed on its outer side, with the knee
considerably bent. The parts were ordered to be kept cool by
the frequent application of evaporating lotion.
The patient remained as quiet as could be expected from a
person in his state of mind, until the third or fourth day, when a
considerable inflammation appeared in the joint, and greatly
increased the previous irritable state of his constitution. Leeches,
fomentations and poultices were applied to the limb, blood was
taken from the arm, purgative medicines were given, and after-
wards saline medicines with sudorifics. Extensive suppuration
n prove.
248 DISLOCATIONS OF THE ANCLE-JOINT.
ensued, and continued for six weeks or two months, when it
began to lessen, and healthy granulations appeared on the whole
wounded surfaces ; about this time the state of his mind began to
Mental improvc, aud it continued to amend as his lear advanced in
symptoms i *-'
recovery. At the end of four or five months the suppurated parts
had filled up, the joint healed, and his mind recovered its natural
tone. At the end of nine months he returned to his employment,
but the ancle joint was stiff. In two years he had so far recovered
as to walk without the aid of a stick, and at the end of three or
four years was able to pursue his avocations nearly as well as at
any former period of his life.
Richard Battlev.
COMPOUND DISLOCATION OF THE TIBIA INWARDS.
CASE IV.
I was sent for on August the 11th, 1814, by Mr. Richards, of
Scale, in Kent, to visit Mr. Knowles, a farmer, residing at Tytham
Farm, aged forty-eight, who, having been thrown from his chaise
against the hinder wheel of a waggon, had dislocated the tibia
inwards, and fractured both the tibia and fibula.
Mr. Richards, who was immediately called to the case, reduced
the dislocation, and endeavoured to heal the wound by adhesion.
When I saw Mr. Knowles, which was ten days after the accident,
the wound wore a favourable aspect. The discharge was abun-
dant, but not in a degree to excite alarm, and all I had to do
was, to praise the judgment which had led to the preservation
DISLOCATIONS OF THE ANCLE-JOINT. 249
of the limb, and to direct the continuance of the means which
had been employed for that purpose.
Before I ventured to state the case to the public I wrote to
Mr. Richards, who informed me that Mr. Knowles's wound was
perfectly healed, and that he walks without the use of a stick.
COMPOUND DISLOCATION OF THE TIBIA
OUTWARDS.
For the following details I am obliged to Mr. Rowley, appren-
tice to Mr. Chandler, Surgeon at St. Thomas's Hospital.
Dear Sir, CASE V.
In answer to your inquiries, I beg leave to forward you the
particulars of Elizabeth Chisnell's case, who was admitted into
St. Thomas's Hospital, on Saturday, May 29th, 1819, with a com-
pound dislocation of the left ancle-joint outwards, occasioned by
her slipping from the foot-path into the road-way. The wound
communicating with the joint was situated upon the outer part of
the leg, and was about four inches in extent, through which the
fibula projected two inches, but it was not fractured ; the liga-
ments connecting the malleolus externus and the astragalus were
lacerated. From the inclination of the sole of the foot inwards,
the whole articulating surface of the joint was so displaced as to
allow two fingers to pass readily across ; and on examination, I
found the extremity of the tibia fractured. The parts were easily
K K
250 DISLOCATIONS OF THE ANCLE-JOINT.
returned to their original situation by extending the foot, the leg
Integuments having been first bent upon the thigh. During the reduction, the
coufiQed
between the inteffumeiits became confined between the malleolus externus and
bones. C3
the astragalus, so as to require an incision upwards by the side
of the fibula, to accomplish the extrication ; that being effected, its
lips were brought together by four sutures, and straps of adhesive
plaster. Splints were applied; and, to subdue the consequent
inflammation, the common application was used.
June 1. The adhesive plaster and sutures were removed,
because the wound and adjacent soft parts around the ancle
were in a sloughing state. Poultices of linseed meal were
ordered to be used daily.
June 5. The sloughs are separated ; the sore is granulating ;
the discharge profuse. A collection of matter has formed upon
the inside of the leg, which was discharged by puncture. The
wound was ordered to be dressed, and a roller was gently applied.
The constitution during this time was but little afifected. Bark
and porter were ordered by Mr. Chandler.
August 7. The wounds are almost healed. The girl sits up
daily, and in a few days she will be allowed to walk.
During the progress of her cure, the constitutional disturbance
has been trifling, indeed, not more than in some favourable cases
of simple fracture : it may be also well to observe that her bowels
were regular during the whole time, so as to preclude the neces-
sity of any laxative medicine, nor did she take any other medicine
than the bark.
I remain, &c. &c.
Soiithwai'k. R. Rowley, Surgeon.
DISLOCATIONS OF THE ANCLE-JOINT. 251
COMPOUND DISLOCATION OF THE TIBIA
INWARDS.
The following accident I was requested to visit, by Mr. Clarke,
surgeon, Great Turnstile, Lincoln's Inn Fields, who has had the
kindness to send me the particulars.
CASE VL
Mr. George Caruthers, aged twenty-two years, had a compound
dislocation of the ancle-joint inwards, with fracture of the tibia,
on October the 6th, 1817. The accident was occasioned by the
overturning of a stage-coach at Kilburn, from whence he was
brought to his house at Lambeth. The end of the tibia projected
through the integuments of the inner ancle, to the extent of from
two by three inches, and the bone was tightly embraced by the
skin. The tibia was fractured, only a small portion of it remaining
attached to the joint; the bleeding was stated to have been
copious, but it had subsided before Mr. Clarke saw him. The
fibula was badly fractured.
For the reduction of the protruded parts it became necessary to
make an incision in the integuments, to loosen them on the tibia;
and when the bone was restored to its place, simple dressings were
spread over the wound. A many-tailed bandage, wetted with an
evaporating lotion, and splints, were applied, and the limb was
placed in the slightly bent position upon a quilted pillow. Bleed-
ing was employed, gentle purgatives given, and saline medicines.
Symptoms of great constitutional excitement naturally arose
K K 2
tional treat-
ment
252 DISLOCATIONS OF THE ANCLE-JOINT.
from so severe a local injury. Abscesses formed on the leg", and
some exfoliations materially retarded the cicatrization of the
wound, producing" also considerable exhaustion of the patient's
constitu- strength. Openings were made into the abscesses, adhesive straps
were placed over the wounds, and lotions were applied on linen,
under oiled silk, which preserved the parts constantly wet. Bark
and wine were given with occasional aperients. Mr. Caruthers
left town on October the 6th, 1818, having then a small opening
on each side of the limb, and suffering occasional pain, but his
general health had been good for some months previous. In
January last, a considerable portion of bone came away, and the
sore immediately healed and has so continued ; he has been ever
since free from pain, and is now in better health than before the
accident. He employs himself in superintending a farm, around
which he walks with one crutch and a stick, but if the ground be
level, with a stick only ; and the limb is becoming daily more and
more useful.* Thomas Clarke.
To Mr. Somerville, of the Stafford Infirmary, I am indebted for
the following letter :
CASES VII. and VIII.
Dear Sir,
I take shame to myself for not having answered your obliging
* In June, 1822, 1 wrote to Mr. Caruthers to inquire how he proceeded, and his answer was, that
he could walk three or four miles easily, and eight if required; and that he would not exchange his
injured leg for a wooden one for the whole of Europe.
DISLOCATIONS OF THE ANCLE-JOINT. 253
queries sooner, as to the cases of compound dislocation of the
ancle which have fallen under my care ; but the fact is, I wished
to g-ive you my answer in the most authentic form by sending' you
a transcript of the cases from the minute books of the Infirmary ;
but after having" caused the most diligent search to be made for
them, I have now the mortification to learn that they are no where
to be found: you will allow me therefore to plead this circumstance
as the real cause of my seeming inattention to your wish, and at
the same time to offer it as an apolog'y for the want of a more
detailed account. I have a distinct recollection of two cases,
though not of the manner in which the accidents were produced.
The first occurred about fifteen years ago, the other a few years
later: they where both dislocated inwards, and were both discharged
cured ; the one at the end of the fifth, the latter not till tlie
seventh week. In the first case the wound, which was lacerated
so as to form a flap, healed by the first intention ; in the latter it
was kept open by the discharge, which was at first purulent, after-
wards limpid ; but no untoward symptom supervened during the
cure. The treatment in both cases was as follows :
After the reduction of the bone the patient was placed upon his
side, with the limb in a bent position ; no ligature was used, but
the lips of the wound were nicely approximated, and retained
in situ by straps of sticking" plaster, of ample lenafth, yet not useofadhe-
•'*■ &r' r G ^ J sive straps.
sufficient to encircle the limb, lest they should, by causing undue
pressure on the supervening tension, excite too much inflammation,
and, in consequence, suppuration. To obviate, however, both
tension and inflammation as much as possible, a plaster, spread
moderately thick with Kirkland's defensative, was placed round defensative.
254 DISLOCATIONS OF THE ANCLE-JOINT.
and in easy contact with the ancle, and over the whole a tailed
bandage was loosely applied. A brisk purgative was given on the
following morning, and low diet was ordered till all danger of
inflammation was over. The adhesive plaster was removed on the
second or third day, and was not renewed ; but a pledget of
melilot digestive was placed over the wound, and the defensative
bandage applied as before. The subsequent treatment consisted
merely in the daily renewal of the pledget, and the proper adjust-
ment of the plaster and bandage, both of which were gradually
drawn tighter round the limb, in proportion as the danger of
inflammation became less, and this operation was performed with
the view not only to give stabiHty to the joint, but also to facilitate
the progress of cicatrization.
The use of the plaster after the manner above mentioned, may,
at first, appear to you a singular practice, but, by being spread
very thick, it seldom requires a renewal during the period of cure ;
unless the discharge from the wound should be so great as to
render a change necessary ; but if it should not, it will appear
obvious that there can be no necessity for disturbing or moving the
limb from its original position, the retention of which 1 have ever
considered, in cases both of compound dislocations and compound
fractures, of the highest importance to facilitate the cure. The
plaster is composed of two parts of emp. plumbi, and one each of
oil, vinegar, and chalk finely powdered ; and I have ever found it a
most powerful repellent in all cases of violent local inflammation.
I am, dear Sir, very respectfully.
Your obliged and most obedient Servant,
Stafford, Aug. SI, IS] 9. Henry Somerville.
DISLOCATIONS OF THE ANCLE-JOINT. 255
COMPOUND DISLOCATION OF THE TIBIA
OUTWARDS.
The following' case I received from Mr. Scan*, surgeon, of
Bishop's Stortford.
CASE IX.
Dear Sir,
John Plumb, the subject of the following statement, was in
the thirty-eighth year of his age when his accident took place,
which Vas about seven years ago. He was in the act of ascending
a ladder with a sack of oats on his shoulders, and had mounted
ten feet from the ground, when the ladder slipped from under him,
and he was precipitated to the ground, lighting on his feet, but still
sustaining the sack of oats on his shoulders. I was passing about
two hundred yards from the place at the moment when the
accident happened, and was, consequently, in immediate attend-
ance. On the removal of his stocking, I found that the tibia and
fibula had penetrated through the integuments at the outer ancle,
and were lying on the outside of the foot ; the articulatory surface
of the astragalus had penetrated through the integuments of the
inner ancle, shewing, on a view of the case, the foot nearly
reversed, the bottom of the foot being placed where the side of
the foot is naturally situated. The wounds through which the
surfaces of the bone had penetrated being free, soon determined
me in the line of conduct I should pursue, viz., to immediately
reduce the joint to its natural situation with as little violence as
256 DISLOCATIONS OF THE ANCLE-JOINT.
possible, and which was effected with much less difficulty than I
expected ; the wounds were brought close by adhesive straps,
the limb placed on its outer side, and cloths applied constantly
moistened with lotion of acetate of lead ; the patient was then
bled to about sixteen ounces ; a saline diaphoretic mixture was
given, and attention was paid to his bowels ; in short, the
antiphlogistic plan was persevered in with due regard to his
constitutional powers : abscesses took place which were opened
in the most favourable points, and after five and twenty weeks
the man was convalescent ; union of the articulatory surfaces took
place, the wounds healed, and the patient became able to walk ;
he could not bear much on his foot to work till about twelve
months after the accident, from which time he has constantly
been labouring in his situation with Mr. Starkis, a gentleman of
respectability of this town, and continues to do so at this time.
It is my intention to send this man up to you, that you may
have a full confirmation of the accident from him, as well as from
Mr. Cribb, my present assistant, who was present at the time of
my being called to him, being at that time with his father, Mr.
Cribb, surgeon, of this town, whom I consulted on the case at the
time of the accident, as well as during its continuance. Trusting
that the statement and result may prove satisfactory to your inquiry,
I am, dear Sir,
Your most obedient,
August 16th, 1819. R. T. Scarr.
P. S. I hope Mr. Cribb and the man will be with you the
beginning of the next week.
DISLOCATIONS OF THE ANCLE-JOINT. 257
This man was sent to town, and I had an opportunity of
witnessing" the happy result of Mr. Scarr's skill and attention.
A. C.
COMPOUND DISLOCATION OF THE TIBIA
INWARDS.
For the following most interesting case I am indebted to a very
excellent surgeon and ingenious man, Mr. Abbott, at Needham
Market, Suffolk. It is an admirable proof of what may be
accomplished in these cases by extraordinary skill and attention.
CASE X.
April 25, 1802, Mr. Robert Cutting, a butcher by trade, near
seventy years of age, corpulent, very intemperate, and subject to
gout from his youth, in a dispute, when in a state of intoxication,
was thrown violently to the ground, and suffered a compound
dislocation of the tibia at the ancle-joint ; the end of it was forced
through the integuments nearly four inches ; the wound was large
and semi-circular ; in the struggle to stand erect, he rested his
weight upon the end of the bone, which was covered with sand
and dirt ; the cavity of the articulating surface of the joint was
filled with blood and sand, the fibula fractured a few inches above
the joint, and the foot completely turned outwards ; in this state
he was placed in an open cart, full four miles from his residence,
Somersham, in Suffolk, about seven miles from Ipswich. It was
near five hours from the time the accident took place, before
L L
Amputation
refused.
258 DISLOCATIONS OF THE ANCLE-JOINT.
surgical assistance arrived, in the middle of a cold night. I
attended with a well informed pupil of mine, Mr. John Jefferson,
who has now resided many years at Islington. A case so formid-
able, a large wound, the connecting ligaments lacerated, the
surfaces of the articulating parts long exposed and much injured,
led me to conclude, that it would be impossible to save the limb,
in a constitution so disordered ; however, no persuasion could
prevail with a mind obstinate and inflexible ; he would not submit
to amputation. The surfaces were, as carefully and expeditiously
as possible, made clean with warm water ; the reduction was
easily accomplished, the lacerated parts properly placed, and the
edges of the wound nearly brought in apposition, without stitches
or adhesive plasters ; the limb was laid upon a proper sized thin
board, excavated so as to take the form of the leg, with an
opening to receive the outer ancle ; this was well padded, the foot-
part raised somewhat higher than the leg; plaits of lint, wetted
with the tinctura benzoini composita, were placed over the wound,
which, in a few hours, formed a hard sealed cap, of a circumference
that effectually excluded the air; a folded flannel bandage was
applied over the limb from the foot to the knee ; and the leg was
laid in a flexed position. V. S. 5 xij. A saline purge was given
every two hours until his bowels were relieved ; milk broth only
was allowed for his support.
Sixteen hours after the dressing his bowels had been properly
evacuated, and he was tranquil. Heat moderate ; a moisture was
spread over the whole surface ; pulse 86 ; and he had some hours
of refreshing sleep.
April 27th. A little heat was raised ; sleep interrupted ; pulse
DISLOCATIONS OF THE ANCLE-JOINT. 259
96 ; surface moist ; darting* uneasiness about the ancle and foot ;
no thirst ; bowels kept cool, and the same support continued :
common saline medicines were resorted to every three hours.
Upon unfolding the flannel some swelling appeared to surround
the ancle : a little gleety discharge had escaped from beneath the
lower part of the dressing. The inflammation did not appear to
be more than might be wished. Lint, wetted with the tincture,
was applied so as to prevent the escape of any discharge ; and to
seal the covering more securely, six leeches were applied at a
small distance from the inflamed part : the wounds bled freely,
and afforded ease.
April 29. He passed a good night ; heat lessened ; free from
thirst ; limb easy without tension ; and the inflammation about
the ancle abated.
April 30th. A quiet, good night; and every symptom appeared
favourable.
May 2nd. The pulse had regained the natural standard.
Upon examining the ancle, a small quantity of pus escaped from
the lower part of the dressing. Lint, wetted in the same manner,
to glue the covering securely, was used. From this time my visits
became less frequent. The tincture was used whenever the sur-
face of the cap appeared to lose its hold. At the end of ten weeks
he was taken from his bed daily, and laid upon a sofa. After the
first stage of symptoms, healthy actions were established, and he
became perfectly healthy. Between the third and fourth month
the cap or dressing was taken from the ancle ; the wound was
completely cicatrised; a small abraded surface appeared over the
L L 2
260 DISLOCATIONS OF THE ANCLE-JOINT.
cicatrix, occasioned by incrusted matter. Simple dressings rendered
the wound sound and well in a few days. During the time of the
curative process the feetor was very trifling. The thickening upon
the wound was not more than might have been expected : the
form of the joint was natural, and bore the appearance of being
perfect. At the end of five months he was allowed to go on
crutches, to place the foot on the ground, and to use such weight
or pressure as his feelings could admit. For many months an
application of oil, obtained from the joints of animals, was made
night and morning, for an hour each time, by friction ; and to
please himself, the patient plunged his foot and ancle in the
paunch of an ox. With these means an imperfect motion in the
joint was recovered, and within twelve months he could walk
without a stick ; he pursued his occupation, and lived to the age
of eighty-three. The last ten years he was able to walk as well
as ever he could. Mr. Jefferson will be able to confirm this
statement.
Since the case of Cutting, I have uniformly, in a variety of
compound fractures, followed the curative plan of treatment by
the first intention. Mr. George Lynn, of Woodbridge, my son-
in-law, a deserving character in his profession, and the late
Launcelot Davie, of Bungay, were pupils of mine, and attended
many cases with me of a very formidable nature, successfully
treated by the same means. A compound fracture of the thigh,
attended with considerable comminution of the bone, occasioned
by a waggon, loaded with twenty-five combs of barley, passing
DISLOCATIONS OF THE ANCLE-JOINT. 261
over it, was perfectly restored by the same treatment, within
six months.
With the greatest esteem,
I have the honour to be.
Your very much obHged,
Needham MarTcet, And faithful Servant,
SuffolJc. Robert Abbott.
COMPOUND DISLOCATION OF THE TIBIA
OUTWARDS.
To Mr. Ransome, surgeon at Manchester, I am indebted for
the following case :
CASE XI.
Dear Friend,
In reply to thy letter, requesting to know the result of my
experience in cases of compound dislocation of the ancle-joint, I
have great pleasure in stating the following case, which has
recently occurred. I take the liberty of briefly describing it, as
there were some circumstances connected with it which did not
afford the most flattering prospect.
In the autumn of last year, a female, aged about forty-five case
strun.
years, of a strumous and leucophlegmatic habit, having a trouble- Jiabit,
some cough and occasional dyspnoea, fell from a high stool, and
pitching upon the left foot, caused a compound dislocation of the
ancle-joint ; the foot was luxated inwards ; the external malleolus
was fractured ; a lacerated wound extended half round the joint.
in a
strumous
262 DISLOCATIONS OF THE ANCLE-JOINT.
and exposed the protruding- portion of the malleolus, laying the
cavity of the joint so open as freely to admit the finger; and
through it the synovial fluid escaped. I removed a portion
of detached bone, reduced the dislocation, and brought the inte-
guments together very slightly; the limb was laid upon the side,
and kept constantly cool with the saturnine lotion combined with
the liq. ammon. acet. ; a small opiate, and a demulcent mixture
were given at intervals. From the constitution of my patient, I
must confess I feared the most serious consequences ; but I was
happily mistaken. Little inflammation followed, the wound
healed without a copious suppuration, and she is now perfectly
recovered, and walks to considerable distances. She was confined
in a very small room, and in a part of the town not very famous
for the purity and salubrity of its atmosphere.
Manchester, I am, &c. &c.
October 22, 1818. T. A. Ransome.
COMPOUND DISLOCATION OF THE TIBIA INWARDS,
AND FRACTURE OF THE THIGH.
To Mr. Chandler, of Canterbury, Surgeon to the Kent and
County Hospitals, I am obliged for the following communication.
CASE XIL
My Dear Sir, Bengal Street, Canterbury,
I take the earliest opportunity of complying with your
request, to furnish you with the result of my observations on
compound dislocation of the ancle-joint.
DISLOCATIONS OF THE ANCLE-JOINT. 263
You will, perhaps, think it singular, that this division of Kent,
which our hospital practice embraces, should be so destitute of
eases giving rise to accidents of this nature, that only two have
occurred, either in my private practice, or at our hospital, or to
my coadjutor, Mr. Fitch, during the last fifteen years ; and as
these are the only instances, I fear it would be deemed pre-
sumptuous in me to form an opinion upon the method to be
adopted, and the probable termination of the generality of acci-
dents of this nature. The favourable result, however, of these two
eases, admitted under my care in the Kent and County Hospitals,
was so firmly impressed on my memory, as to confirm unequivo-
cally the precepts you early inculcated, to save the limb if
possible in compound dislocations of the ancle-joint. In accom-
plishing so desirable a point, the advantages obtained in a country
hospital, will, I apprehend, bear a great proportion in the scale of
success, compared with the circumstances of a patient placed in
a crowded infirmary of a large manufacturing town, or in the
metropolis ; the constitution will, in general, be less impaired by
excess, poverty, and other evils ; whilst purity of air in large
ventilated wards will materially contribute towards recovery, even
if the injury to the joint be extensive; we consequently can be
permitted to take greater latitude with our curative means upon
an injured joint, relying on the powers of nature, without being
under the immediate necessity of anticipating the issue resulting
from unfavourable habits, and in situations inimical to disease.
My notes furnish me only with the brief details of one case.
July, 1818. A bricklayer, aged thirty-six, of slender make, but
of good constitution and of sober habits, fell from a height of
264 DISLOCATIONS OF THE ANCLE-JOINT.
between thirty and forty feet upon loose materials for building^
and alighting upon his feet, received a very severe shock, attended
with comatose symptoms, a fracture of the right thigh, a consi-
derable contusion and laceration of the left ancle-joint, accom-
panied W'ith a dislocation of the bones inwards, the tibia resting
upon the inner side of the astragalus ; a portion of the lower
extremity of that bone was fractured, and the fibula was broken
about three inches above the malleolus externus, and the sur-
rounding ligaments of the joint were lacerated ; little difficulty
was found in reducing the dislocation, and in replacing the frac-
tured bones; but in consequence of the violent injury done to
the joint, a question arose on the propriety of amputation. As
the man had enjoyed uninterrupted health, and was of the con-
stitution and habit least liable to the attack of inflammatory
afi'ection, I ventured to give him a chance of saving the limb.
An union by the first intention of the external wound, as far
as practicable, was attempted, and the limb was laid in the most
convenient, yet relaxed and easy posture. Evaporating lotions
were applied, and the strictest antiphlogistic system enjoined.
Considerable inflammatory symptoms ensued, with a copious
discharge of synovial fluid; the limb and joint were much swollen,
and it became necessary to vary the treatment by applying warm
spirituous and opiate fomentations and poultices, which appeared
more genial to the patient's feeling, and were therefore continued.
to'gangreM. A dispositiou of the contused parts to gangrene appearing,
Sic acid.""' muriatic acid was added to the cataplasm, and the medicines
were changed according to the effect produced on the constitution
by symptomatic irritation accruing from the discharge. The
DISLOCATIONS OF THE ANCLE-JOINT. 265
disposition to g'angrene ceased soon after the application of the
muriatic acid : from this medicine I have often derived, in similar
circumstances, great advantage. After the first fortnight, my
hopes of saving the limb were confirmed by the abatement of
pain and swelling, and by the mitigation of the constitutional
symptoms, the colour of the discharge improving, with less
synovia, and granulations arising round the wound. The patient
continued gradually to improve till about the tenth week, when
the wound was nearly healed. This man was discharged in
fourteen weeks quite well, although with rather an unsightly and
partially stiff joint.
The other case, of which I have notes, was also a compound
dislocation of the ancle-joint, but without the degree of injury
sustained in the former; this patient was also discharged cured.
I have now to apologize for trespassing upon your time, in the
attempt to give you the details of cases that might have been
interesting if not so curiously drawn up ; but as my notes were
only penned to furnish me with hints for the future, from the
distance of time, the minutes have escaped my memory, and I
doubt that they are too inaccurate and too inconclusive to afford
you any information ; but the occasion serves me as a pretext
for assuring you how much
I remain.
My dear Sir,
Your very faithful and obliged Servant,
W. Chandler,
M M
266 DISLOCATIONS OF THE ANCLE-JOINT.
Royal Navy Hospital, Plymouth,
August n, 1819.
My DEAR Sir,
In answer to your letter inquiring of me whether I had had
any cases of compound dislocation of the ancle-joint, with their
treatment and their result, I beg leave to acquaint you, that
several of the above nature have fallen under my care and
observation, during the eight years I served as assistant-surgeon,
and the sixteen years I have been the first surgeon of this hospi-
tal; during nearly the whole of which period the country was
engaged in active naval warfare, and, consequently, this hospital
was in the constant receipt of important surgical cases ; and I have
also witnessed a few more from other causes. The result of my
observations have been, that in cases of compound dislocation of
the ancle-joint there is not only a chance of saving the limb, but
of that limb being at a future time useful. The dislocated bones
should be replaced in their situation with as little violence and
injury as possible to the surrounding parts ; and should any
difficulty arise in returning the bones, from the smallness of the
wound, I freely enlarge it with a scalpel. After they are replaced,
I lay the limb perfectly extended on very soft cushions of lint
arranged on three pillows, the centre one reaching the length of
the leg, the upper one crossing under the ham and inferior part
of the thigh, and the lower one crossing under the heel, having
previously placed on these pillows a fine sheet, folded so often that
when its edges are turned in, it may protect the limb from the
pressure of the splints ; under this sheet are laid several slips of
calico, about eighteen inches long and three broad. When the
DISLOCATIONS OF THE ANCLE-JOINT. 267
limb is thus comfortably placed, taking care to fill up every hollow
with lint, I draw the edges of the lacerated integuments as near
together as they can be brought by the gentlest means, retaining
them Avith small slips of adhesive plaster, and covering this with
pledgets of soft lint ; this done, I direct the foot to be kept very
steady, whilst I ultimately place the slips of calico, already des-
cribed, over the whole length of the extremity, draw up the edges
of the sheet, and apply on each side of the leg, outside of all, a
very broad splint of common deal, of such length as to reach at
least three inches below the foot, and as far above the knee-joint ;
these splints are well covered with lint, and then so secured as
to afford support (but no pressure) to the whole of the leg and
foot, the breadth of the splint materially contributing to the latter
purpose, and allowing the tape to pass around the limb without
injury. The foot ought also to be prevented from dropping or
altering in the least its position, by passing a broad tape through a
hole in the lower ends of the splints, which tape is to be tied,
securing between it the sole of the foot, which will effectually
keep it up, and securing it further by a stirrup bandage ; when
every thing is thus accomplished, the foot and leg are directed to
be kept constantly wet with cold water, taking care not to sponge
it immediately over the wound. The subsequent treatment of the
patient must depend upon the symptoms which arise. This is the
plan I pursue in those cases where there is a probability of saving*
the limb. I have seen more than one case, where, after great
perseverance and risk, the limb has been saved, but when the
wounds were all healed, has been found of little or no use ; as an
example, a man who had had a compound dislocation of the ancle
MM2
268 DISLOCATIONS OF THE ANCLE-JOINT.
in the West Indies, from whence he was sent to England as an
invalid, became my patient in this hospital, and when received, a
period of thirteen months from the accident, had the whole of the
lower head of the tibia (although in its proper situation) exposed,
black, and carious, which at the end of a year and a half came
away, more than three inches in length ; and at the expiration of
three years and a half from the injury, he quitted the hospital,
with the wound healed, but with a shortened, deformed, and
anchylosed leg, liable to break out on the slightest injury. The
great question to be decided, however, in these accidents is, in
what cases the surgeon is justified in attempting to save the limb,
and in what cases immediate amputation is necessary. From all I
have seen, I should not hesitate to advise the immediate removal
of the limb, where the lower heads of the tibia and fibula are very
much shattered ; where, together with the compound dislocation
of these bones, some of the tarsal bones are displaced and injured ;
where any large vessels are divided and cannot be secured,
without extensive enlargement of the wound and disturbance of
the soft parts ; where the common integuments, with the neigh-
bouring tendons and muscles, are considerably torn ; where the
protruded tibia cannot by any means be reduced ; where the
constitution of the patient is enfeebled at the time of the accident,
and not likely to endure pain, discharge, or long confinement.
I have a fine specimen of injury done to the tibia, fibula, and
tarsal bones, from a compound dislocation, requiring amputation
ten months after the accident, which occurred in the Mediter-
ranean ; it is very much at your service to see or copy, but I
must beg of you to have the goodness to return it, as it forms
DISLOCATIONS OF THE ANCLE-JOINT. 269
part of a collection of bones which I have been forming for the
last twenty years. (See plate.)
I am, &c. &c.
Stephen L. Ham3iick.
I beg Mr. Hammick to accept my thanks for his excellent letter.
The following case shews that under the most unfavourable
circumstances, these injuries are not destructive of life, in persons
of good constitutions.
CASE XIII.
Winchester, jiugust \st, 1819.
My dear Sir,
In answer to your inquiries of my practice in compound
dislocations of the ancle-joint, I can only say, that in almost every
case that I have witnessed, the general injury has been so great
as to require amputation. I recollect but one case in which
amputation was not necessary ; it was that of a patient at a dis-
tance, to whom I was called by a neighbouring practitioner about
five weeks after the accident, " to reduce a dislocation of the
ancle, as he had reduced the fracture of the fibula." I saw the
patient, but the fractured fibula was so firmly united, that a
reduction could not be attempted ; the compound dislocation
gradually got well, if you can call the greatest deformity I ever
saw, well ; however, no bad symptoms arose, and I am persuaded,
that had the dislocation been at first reduced, the case would have
terminated in a most satisfactory manner.
270 DISLOCATIONS OF THE ANCLE-JOINT.
I had a case of compound fracture of the elbow-joint, in the
person of Dr. Wool, now head master of Rugby, which did well,
without leaving- any perceptible degree of stiffness.
I remain, my dear Sir,
Your's very truly,
W. WiCKHAM.
28, ParJc Street, Bristol ;
October 20th, 1818.
My DEAR Sir,
During the twenty-two years I have been Surgeon to the
Bristol Infirmary, and I believe during my apprenticeship there,
making in all nearly thirty-years, it has been our invariable
practice to endeavour to save the limb in cases of compound
dislocation of the ancle, unless where the chance was annihilated
by some concomitant injuries or circumstances ; but as a general
rule it was always adhered to, which it would not have been
unless the great majority of cases had done well. We save the
limb in private practice almost invariably, unless in very bad
cases indeed.
I am, my dear Sir,
Your's, &G.
R. Smith.
DISLOCATIONS OF THE ANCLE-JOINT. 271
COMPOUND DISLOCATION OF THE TIBIA
INWARDS.
My friend, Mr. Fiske, surgeon at Saffron Walden, stated to
me the following case :
CASE XIV.
A man, aged sixty, had ascended a ladder to a considerable
height, when, accidentally slipping, he fell to the gromid. Mr.
Fiske being called to him, found the tibia dislocated inwards
at the ancle-joint, and the end of the bone, covered by its cartilage,
protruding through the integuments. He immediately replaced
the bone, brought the integuments together by adhesive plaster,
applied a bandage over the joint, and splints upon the limb,
directing him to remain as quiet as possible. The wound healed
without any untoward circumstance, and the man not only reco-
vered, but has obtained an extremely useful limb.
COMPOUND DISLOCATION OF THE TIBIA FORWARDS,
AND TWO CASES OF THE TIBIA OUTWARDS.
I have received the following cases of injury to the ancle
from Mr. Maddocks.
CASE XV.
Dear Sir,
These cases are of recent date, and I have a perfect recol-
lection of every important circumstance connected with them.
272 DISLOCATIONS OF THE ANCLE-JOINT.
The first happened to a stout healthy young' man, who, by a fall
from a vicious horse, dislocated his ancle. The accident happened
a few miles from Nottingham. He was immediately brought to
his master's house, where 1 saw him, and found the end of the
tibia protruding through a large lacerated and contused wound,
on the fore part of the ancle. The fibula was broken about four
inches above the joint, and its lower end was separated from its
connection with the tibia, by a laceration of the ligament con-
necting it with that bone, but it did not protrude. Appearances
in many respects were unfavourable, as there was much liga-
mentary and some tendinous laceration ; but as the tibia was
sound, and the fibula only transversely fractured, I was encouraged
by the resources of a good constitution, and more particularly by
the sanction of my friend, Mr. Wright, a practitioner of much
experience, to attempt the preservation of the joint. The bones
were reduced with little difficulty, and the limb was placed in a
flexed position on its side on a broad hollow splint; the super-
vening* symptoms were more favourable than could have been
expected from the nature of the accident, though some portion of
the integuments sloughed away, and two different suppurations
took place in the joint, followed by two small exfoliations. The
patient in three months recovered the use of the joint, and at this
time experiences no inconvenience from the accident.
Two cases of external dislocation occurred in boys, both of
whom were healthy, and the accidents were occasioned by falls
from horses ; the malleoli interni were in both instances broken
off*, and the tibia and fibula protruded two or three inches through
the integuments. In one case, the projecting end of the fibula
DISLOCATIONS OF THE ANCLE-JOINT. 2/3
was left, adhering- by its ligament to the anterior part of the
astragalus ; in the other it was whole. I removed the loose
portion of the fibula, the bones easily united, and the limbs
were placed in an extended position, supported by long splints.
In both cases the inflammation was high. In one, a large abscess
formed about the middle of the leg, and a discharge of matter
from the joint continued for some weeks, attended with a separa-
tion of sloughing ligamentous and membranous parts. The wound
gradually healed, the discharge abated, and the boy recovered,
with very little impediment to the free motion of the joint. The
other boy would have been equally fortunate, but exfoliations took Exfoliation
^ of the tibia.
place on the end of the tibia, which, though small, retarded his
recovery for several weeks, and left the joint less perfect in its
motion than in the preceding case, but quite sufficient for the
common occupations of life. You have here a plain statement of
facts, without comment or embellishment. My mode of treatment
has been uniformly to keep the limb in the most quiescent state,
and to meet symptoms as they arise ; and I cannot but attribute
the success which attended the treatment of these cases in a
great measure to that precaution,
J am, dear Sir,
With great respect, your's
B. Maddocks,
N N
274 DISLOCATIONS OF THE ANCLE-JOINT.
DISLOCATION OF THE TIBIA AND FIBULA
OUTWARDS.
CASE XVI.
Sir,
Not having* the honour of being' personally known to you, I
trust that the wish you have expressed in your work on dislo-
cations to be informed of the treatment and result of accidents
of that nature, will plead my excuse for troubling you with the
following- case of compound dislocation of the ancle.
On the 22nd of October last, I was called upon to attend
Thomas Saxty, a lad about thirteen years of age, whose left foot
had got entangled in a strap of the machinery used in the clothing
business. On examination, I found a very bad compound dis-
location of the tibia and fibula outwards ; the bones were pro-
truding four or five inches through the integuments, which were
dreadfully lacerated ; the wound extended from the external
malleolus in an oblique direction to the posterior part of the tibia,
and within five inches of the head of that bone, which articulates
Avith the femur. On putting my fingers into the cavity of the
ancle-joint, I found the astragalus very loose, being torn from
its connecting ligaments.
On the first view of so serious an accident, I thought it would
be impossible, with safety to my patient, to save the limb ; but
as he had received so severe a shock, the countenance being-
pale, and the extremities cold, I determined to defer the amputa-
tion until the constitution should be recovered from the first
DISLOCATIONS OF THE ANCLE-JOINT. 275
impression of the accident, and proceeded in reducing the limh to
its proper situation, which I accomplished with but little difficulty ;
I applied lint to the wound, and covered the limb with a many-
tailed bandage lightly bound on ; still I had no idea but that
amputation must take place, and the next morning 1 requested
Mr. Carey, a very intelligent surgeon of this town, to assist me in
the operation ; owing to professional engagements, he could not
accompany me to the boy before six in the evening, when, on
examining the limb, there was considerable inflammation in the
leg above the lacerated parts, and great tenderness in the thigh,
which I then learnt had received some injury at the time of the
accident. Under these circumstances, it Avas determined to delay
the operation for the present. The limb was wrapped in a warm
poultice of oatmeal and yeast, the boy placed on his left side with
the limb in the bent position, and a draught with twenty drops of
laudanum ordered to be taken immediately ; he passed a restless
night ; on the following morning, October 24th, the inflamma-
tion of the leg above the injury was considerably increased, with
very great tenderness on pressure ; and the wound had a dry,
dark, sphacelated appearance. I ordered my patient some wine
and an opiate at bed-time ; he passed a more comfortable night,
and the next morning the appearance of the wound had improved;
in the course of the 26th, a distinct line, marking the extent of
mortification, could be traced.
It would be useless to record the daily progress of the case, as
the detail would take up too much of your valuable time ; suffice
it to say, that in the course of three weeks the whole of the
sphacelated parts had separated, leaving a most extensive wound.
N N 2
276 DISLOCATIONS OF THE ANCLE-JOINT.
The poultices were now laid aside, and simple dressings substi-
tuted ; a many-tailed bandage was applied to give support to the
limb, and a splint attached on each side the leg. The discharge
about this time, a month after the accident, was very consider-
able; but the boy having a good constitution, I began to think
there might be some chance of saving the limb, and I deter-
mined not to amputate unless the symptoms should imperiously
demand that operation. About four inches of the inferior extre-
mity of the fibula were exposed to view, and would evidently
exfoliate.
On November the 26th, I placed the boy on his back, the limb
resting on the heel : I was induced to make this alteration in his
position because ray patient had experienced considerable pain
every time the limb was dressed, as it was obliged to be moved
daily for that purpose.
The wound at this time did not go on so well as could be
wished ; it had an unhealthy appearance, with large, flabby, and
shining granulations. I tried the effects of stimulants, such as a
weak solution of nitrate of silver, a solution of vitriolated zinc.
Sec, but still without decided benefit.
On November the 30th, nearly six weeks from the time of the
accident, that part of the fibula which forms the external malleolus
exfoliated ; and tliree days afterwards I succeeded in bringing
away a broad portion of the articulating surface of the tibia. In
a few days the discharge lessened, but there seemed no disposition
in the wound to heal.
I had repeatedly witnessed the good effects of the adhesive
plaster in ulcers of the leg, in the manner recommended by the
DISLOCATIONS OF THE ANCLE-JOINT. 277
late Mr. Baynton ; and, as in the present case, a stimulant was
required, as well as support to the edges of the wound, I con-
sidered that this dressing', applied in the form of a many-tailed
bandage from the ancle to within four inches of the knee (the
extent of the wound), would in all probability amend its condition
and appearances. I was not disappointed, for in the course of a
few days after the application of the plaster the wound began to
heal ; and from that time to the present the rapidity of the cure
has been beyond my most sanguine expectations.
The boy is now, fifteen weeks from the time when he received
the injury, able to walk, with the assistance of crutches, to the
factory, a distance of half a mile from his house. To-day I
observed that he could put the foot flat on the ground, and walk
across the room without the assistance of a stick.
For the last two months I have daily given passive motion to
the ancle-joint, but I fear, from the great extent of injury, that he
will never recover the perfect use of it, though it is not so com-
pletely anchylosed as to prevent all motion.
It appears wonderful that in such a very extensive laceration,
no artery requiring a ligature should have been wounded.
I do not claim to myself the merit of having saved the boy's
limb, as you will perceive by the preceding statement, that he is
more indebted to a fortuitous circumstance. At the time when
my friend, Mr. Carey, saw it, there was too much inflammation
above the seat of the injury to warrant us in amputating.
I have sent you the portions of bone that have exfoliated, as I
thought they would give you a clearer idea of the extent of the
injury to the joint than could be afforded in writing.
278
DISLOCATIONS OF THE ANCLE-JOINT.
I recollect about nine years ago, when I was with my father at
Wantage, the occurrence of compound dislocation of the ancle
inwards, in a woman about fifty years of age and of spare habit ;
it was attended with but little laceration, was easily reduced, and
eventually the patient recovered, but with a complete anchylosis
of the joint.
Should any circumstance occur during the further progress of
the cure, which I should think Avorth communicating to you, I will
take the liberty of again addressing you; or should I have omitted
any thing in the preceding statement which you consider of
consequence, I shall be very happy in giving you any further
information in my power.
I remain.
Your obedient, humble Servant,
J. Ormond.
Trowbridge, Feb. 6t7i, 1822.
REMOVING THE ENDS OF THE BONES.
Sawing off
the ends of
the bones.
Reasons.
Difficult
reduction.
There is another mode of treatment in these accidents, which
consists in sawing off the extremity of the tibia before the bone is
returned into its natural situation ; and the reasons which may be
assigned for pursuing this practice are as follow :
First. That there is in some cases much difficulty in the
reduction of the tibia, and great violence must be employed to
effect it.
rntation
minished.
DISLOCATIONS OF THE ANCLE-JOINT. 279
Secondly. The extremity of the bone is often broken obliquely, obiique
• 1 -I fracture.
SO that when reduced it will not remain upon the astragalus, but
when the point is removed by the saw, it rests without difficulty
upon that bone.
Thirdly. The spasmodic contractions of the muscles are much spasms.
diminished by shortening" the bone, as it throws them all into a
state of relaxation ; whereas, if the bone be reduced by violence
when the saw has not been used, the spasm of the limb will be
sometimes very violent.
Fourthly. The local irritation is much diminished by the Local
•' •' irritati
greater ease with which adhesion is produced of the sawn ex- '*''"'
tremity of the bone to the parts to which it is applied ; for it is
a mistake to suppose that the sawn end of the bone will not
adhere ; the contrary is seen in amputation in sawing off a bone
in exostosis, and in the union by adhesion of compound fractures ;
and that adhesive matter can be thrown out upon cartilaginous
surfaces is known to every person who has dissected a diseased
ioint ; and it is thus that the end of the tibia adheres to the
surface of the astragalus.
Fifthly. When suppuration does occur it is much diminished, ^"pp)]'^^*'°"
and a considerable part of the ulcerative process is prevented by {^^^"^^^^
the mechanical removal of the cartilage ; for nearly half the
articular surface of the joint no longer remains. Ceeteris paribus,
therefore the case recovers more rapidly.
Sixthly. The constitutional irritation is very much lessened by i ess con-
the diminution of the suppurative and ulcerative process, and by '"^"'^t'™-
the ease with which the parts are restored. In the cases which I
280 DISLOCATIONS OF THE ANCLE-JOINT.
have had an opportunity of seeing* there was not more irritative
fever than in the mildest cases of compound fracture.
Boneshat. Seventhly. It has been found that in cases in which the
extremities of the bones forming" the joint have been broken into
small pieces, and in which these have been removed by the finger,
the patient has suffered less, and has more quickly recovered, than
when the bone has been returned whole.
No case of Eio^hthlv. I havc known no case of death when the extremities
death. ^ •'
of the bones have been sawn off, although I shall have occasion
to mention some in which the cases terminated fatally when this
was not done.
Objections. Thc objcctious which may be made to this mode of treatment
Limb shorter arc, that the limb becomes somewhat shorter by the removal of
the cartilaginous extremity of the bone ; but this I do not think
an objection of any considerable weight, if the danger of the case
be, as I believe, lessened by it ; for the diminished length, which
is very slight, is easily supplied by a shoe made a little thicker
than usual.
Anchylosis. The othcr objection is, that the joint becomes necessarily
anchylosed. I doubt very much the reality of this objection, as in
two instances I have seen the motion of the part remain ; but
even when the joint becomes anchylosed, a consequence to which
it is liable in either mode of treatment, still the motion of the
tarsal bones becomes so much increased as to compensate for that
of the ancle, and the patient walks with much less halting than
would be imagined, and has a very useful limb.
useful. It is not my intention, however, to advocate either mode of
DISLOCATIONS OF THE ANCLE-JOINT. 281
treatment to the exclusion of the other, but to state the reasons
which may be justly assigned for the occasional adoption of either.
It is only by a comparison of the different results of varied prac-
tice that a safe conclusion can be drawn ; and from what I have
had an opportunity of observing in my own practice, and of learn-
ing from that of my friends, I feel disposed to recommend to those
whose minds are not settled upon the subject, not hastily to deter-
mine against either treatment in the different cases of this injury,
as, from each mode, under varied circumstances, a strong and
useful limb has been saved without any additional risk to the
life of the patient.
If the dislocation can be easily reduced without sawing off the cases in
•/» 1 • which the
end oi the bone; if the bone be not so obliquely broken, but on^ or the
^ *' other should
remain firmly placed upon the astragalus when reduced; if the ^'^'""'''"y*''*
end of the bone be not shattered, for then the small loose pieces
of bone should be removed, and the surface of the bone be
smoothed by the saw ; if the patient be not excessively irritable,
so as to occasion the muscles to be thrown into violent spasmodic
actions in the attempt at reduction, which leads to subsequent
displacement when the limb has been reduced ; the bones should
be at once returned into their places, and the parts should be
united by the adhesive inflammation ; but rather than amputate
the limb, if the above circumstances were present, I should
certainly saw off the ends of the bones.
I shall now proceed to state the cases which I have myself had cases.
an opportunity of witnessing, and some which have been furnished
by my friends, and shall leave the reader to judge of the propriety
of the advice I have given.
o o
282 DISLOCATIONS OF THE ANCLE-JOINT.
COMPOUND DISLOCATION OF THE TIBIA
OUTWARDS AT THE ANCLE-JOINT.
CASE L
I was sent for to Guy's Hospital, to see Nathaniel Taylor, aged
thirteen years, and was directed to bring ray amputating instru-
ments with me, being informed that the boy had so bad a
dislocation of the ancle that the limb could not be saved.
As soon as I arrived at the hospital, I ordered the patient into
the operating theatre ; and making enquiries into the cause and
nature of the accident, I found it to be as follows: The injury had
been occasioned by a boat falling upon the leg. A large wound
appeared at the outer ancle, through which the tibia and a
fractured extremity of the fibula projected ; one inch of the
malleolus externus remained attached to the astragalus by its
natural ligaments ; the foot was turned inwards so as to be
capable of being brought in contact with the inner side of the
leff : and as the muscles v»ere no longer on the stretch the foot
^'3 5
S^
was very loose and pendulous. I tried to reduce the limb, but
found that the bone could only by great violence be brought
on the astragalus, and that it immediately slipped from its place.
The case was, therefore, as regarded the state of the parts, the
most unfavourable possible, and those around me urged an
immediate amputation ; but seeing the character of health which
the boy bore, I thought J should not be justified in probably
dooming him to a life of mendicity, and I determined to try to
preserve the limb. Finding that the lower end of the fibula,
DISLOCATIONS OF THE ANCLE-JOINT. 283
although still connected by ligament, was very loose and move-
able, I removed it with the scalpel; I then sawed off half an inch Removal of
the end of
of the lower extremity of the tibia. When these operations had 'I'e fibula.
been accomplished with the greatest care, I reduced the bones,
and they maintained their situation, as there was no force of
muscular action upon them, on account of the shortening of the
bones. Lint, dipped in the patient's blood, was then applied,
with adhesive plaster over it; and the leg was put in splints,
and placed on the heel. Scarcely any constitutional irritation
occurred ; the wound and ancle-joint secreted but little matter,
and gradually healed. On the 17th day, an abscess shewed
itself on the tibia, which was suffered to burst, as it had little
affected his constitution. In two months he was allowed to
sit up and use his crutches. In twelve weeks the wound was
healed, and the boy was able to bear on his foot ; and at the end
of four months, he walked well. I experienced inconceivable
pleasure in seeing this boy walk before the students, at my desire,
from one end of the ward to the other, four months after the
accident, with very little lameness. There seemed to be some
motion at the ancle, but the tarsal bones soon acquired sufficient Motion of
the tarsal
mobility to give to the foot so much play as to prevent the articulation.
appearance of stiffness, which a partially anchylosed state of the
ancle would otherwise have produced.
002
2Si DISLOCATIONS OF THE ANCLE-JOINT.
COMPOUND DISLOCATION OF THE TIBIA INWARDS,
CASE II.
West, Esq., aged forty, on December 11th, 1818, jumped
out of his one-horse chaise, alarmed by the horse kicking. He
fell, and when he attempted to rise, found his left ancle dislocated,
and the bone projecting through the skin. Mr. Mackinder,
surgeon, brought him to the house of his father-in-law, in London,
where Mr. Jones, of Mount Street, and myself attended him.
lutegumenis Upoii cxaminatiou of the part, I found the tibia projecting at
pressed be-
tween the the inner ancle through the integuments, which were nipped
under the projecting bone into the joint ; the foot was loose and
pendulous, and very much thrown outwards. Having prepared
several pieces of linen to form a many-tailed bandage, and pro-
cured pillows and splints, the patient was placed on a bed on his
left side, and an attempt was made to reduce the bone; but
hearing from Mr. Jones, that Mr. W. was of a most irritable
constitution, and finding that most powerful extension must be
made, and that the integuments must be divided opposite to the
joint, so as to lessen the probability of an easy adhesion to the
wound, which was placed one inch and a half above the articula-
tion, I sawed off the end of the tibia, and the bone most easily
returned into its natural situation, in which it remained without
difficulty. The edges of the wound were brought together by
a fine thread, so as to be very closely adapted to each other,
and lint dipped in blood was applied over the wound ; the many-
tailed bandage was used ; the limb was placed on its outer side.
1
DISLOCATIONS OF THE ANCLE-JOINT. 285
with the knee hent nearly at right angles with the thigh, and
splints were applied. The leg was ordered to be kept constantly
wet with the liq. pliimbi, s. acetat, dilutus, 5 v. and spir. vini.
si.; a dose of opium was given to him, and ten ounces of blood
were taken from his arm. In the evening, more opium was
administered, and a dose of infusion of senna and sulphate of
magnesia was ordered for the morning.
Dec. 12. As the limb felt hot, the upper splint was removed,
its pressure being somewhat painful, and preventing free evapo-
ration. Opium was ordered at night.
Dec. 13. The foot was vesicated. He had chillness succeeded
by heat ; slight tension of the leg, and some pain for three hours.
His mind was much agitated by seeing his children.
Dec. 14. The limb was less inflamed, and he had scarcely any
constitutional irritation.
Dec. 15. A slight discharge of serum mixed with red particles
from the wound; some pain in the foot and leg, but no irritative
fever.
Dec. 16. There was more discharge, and some air passed
from the wound ; a poultice was applied, and a generous diet
allowed, as his stomach, naturally weak, had become very
flatulent. Pulse 90.
Dec. 17. A fomentation and poultice applied.
Dec. 18. The discharge was becoming* purulent; but as his oerange.
^ or' mentofthe
stomach was deranged, he was visited by Dr. Pemberton, who ^'°™a«=''-
ordered him hyoscyamus with the mixturar camphor, in the day,
and opium at night.
From this time to the 7th of January, the discharge from the
286 DISLOCATIONS OF THE ANCLE-JOINT.
limb was copious, but it then began to lessen ; and when the leg
Avas examined on the 12th of January, it had become firm ; a
small wound remained, on which the granulations were prominent.
In the first week in Februrary, he was allowed to get upon his
sofa, the limb being now firm, and only a small wound remaining,
from which an exfoliation will occur, as the bone can be felt bare.
In August I saw him ; the wound still remained open, and the
portion of bone had not separated.
This gentleman, with the worst constitution in regard to the
state of his stomach, did not suffer so much irritation, as a com-
pound fracture usually produces.
COMPOUND DISLOCATION OF THE TIBIA INWARDS.
Mr. Charles Averill, dresser to Mr. Forster, Surgeon of Guy's
Hospital, had the kindness to send me the following particulars of
a case, the progress of which I often witnessed with pleasure.
CASE III.
John Williams, sailor, aged thirty-eight, a very robust man, was
brought into Guy's Hospital, under the care of Mr. Forster,
August 9th, 1819, at four o'clock in the morning, with a com-
pound dislocation of the right ancle inwards, and considerable
injury to the left, occasioned by his falling from a height of about
twenty-six feet, in endeavouring to escape from the Borough
Compter, in which he was imprisoned. On examining the injured
I
DISLOCATIONS OF THE ANCLE-JOINT. 287
part, I found the tibia protruding three inches through a large
transverse wound of four inches in extent, and resting on the inner
side of the os calcis ; the cartilaginous surface of the astragalus
could be readily felt on passing my finger into the wound ; the
fibula was broken. I first sawed off the whole of the cartilaginous
end of the tibia, when the bone was easily replaced ; the edges of
the wound were then brought as much in contact as possible ; lint
dipped in blood was applied, and over it straps of adhesive plaster;
the foot and leg were wrapped in cloths wet with a lotion of
acetate of lead, and the limb was laid on its side. He complained
of great pain in the left leg, which was very much swollen ail
around the ancle ; ten leeches were applied to it, and afterwards
the liquor plumbi subacetatis dilutus, which relieved the pain ;
thirty drops of laudanum were given, and he remained easy. On
the following day, sixteen ounces of blood were taken from him,
and five grains of calomel were given. On the 12th, the
dressings were removed; the wound looked well. On the 17th,
suppuration had commenced, and the discharge having rather a
foetid smell, the nitric acid lotion was applied.* September 2nd, use of nitric
acid in
the matter gravitating to the outer side of the leg, an opening ^'""^J'"^
was made, by which it was discharged, and adhesive plaster
applied to the original wound, which was healing fast; the dis-
charge gradually diminished, and on the 21st of September, six
weeks from the accident, both wounds were quite healed. He has
* The nitric acid lotion, during the sloughing process, is the best application with which I am
acquainted. I order it in the proportion of fifty drops of the acid to a quart of distilled water, and
apply it by linen covered with oiled silk.
288 DISLOCATIONS OF THE ANCLE-JOINT.
not yet left his bed. There is motion at the ancle ; the toe turns
out but very little, and does not point downwards. He wears
splints, and the strength of the limb is daily increasing. When
the swelling of the left ancle diminished, a fracture of the external
malleolus was also there discovered.
Charles Averill.
October ith, 1819.
This man escaped from the hospital on the 24th of October, and
two months afterwards was retaken, and is now in the Borough
Compter. He has free motion of the right ancle, and suffers more
from the injury to the left.
For the following letter I am indebted to Dr. Kerr, of North-
ampton, who, at the age of more than eighty, still continues to
practice his profession with all the ardour of youth, and with a
strength of intellect which has been seldom surpassed.
Northampton, July 28th, 1819.
My dear Sir,
I have had the honour of your letter this morning respecting
compound dislocation of the ancle ; several such cases have fallen
under my care, and it has been uniformly my practice to take off
the lower extremity of the tibia, and to lay the limb in a state of
semiflection upon splints ; by this means a great deal of painful
extension, and the consequent high degree of inflammation, are
avoided. The splints I use are excavated wood, and much wider
than those in common use, with thick moveable pads stuffed with
DISLOCATIONS OF THE ANCLE-JOINT. 289
wool. I keep the parts constantly wetted with a solution of liquor
ammonise acetatis, without removing- the bandage. In my very
early life, upwards of sixty years ago, I saw many attempts to
reduce compound dislocation without removing any part of the
tibia ; but, to the best of my recollection, they all ended unfavour-
able, or, at least, in amputation. By the method which I have
pursued, as above mentioned, I have generally succeeded in saving
the foot, and in preserving a tolerable articulation.
I am, with much esteem, my dear Sir,
Your obedient, humble Servant,
William Kerr.
COMPOUND DISLOCATION OF THE TIBIA
OUTWARDS.
To Dr. Rumsey, of Amersham, I am obliged for the following
interesting communication.
. CASE IV.
Dear Sir, Amersham.
I have the pleasure of forwarding to you the case of a com-
pound dislocation of the ancle, which came under my care many
years ago, and which had a fortunate termination, as the patient
lived many years after the accident.
On June the 21st, 1792, Mr. Tolson, aged forty years, was
thrown from a curricle on Gerrard's-cross Common, eight miles
from this place. The injury he received consisted in a compound
P P
290 DISLOCATIONS OF THE ANCLE-JOINT.
dislocation of the tibia and fibula at the outer ancle of the left
leg-, with a fracture of the astragalus (the superior half of which
was attached to the dislocated bones of the leg), and likewise a
Complicated simplc fracturc of the os femoris on the same side. He was
with frac- /••ii i
tureofthe couveved to a friend's house on the common, where he had the
femur. *^
advantage of an airy, healthy situation, with every kind of
domestic attention. I saw him about two hours after the accident,
and found the bones protruding at the ancle through a very large
wound, with the foot turned inwards and upwards, and the integu-
ments beneath the wound exceedingly confined by the dislocated
bones which descended nearly to the bottom of the foot. A con-
siderable haemorrhage had taken place, but was stopped by the
spontaneous contraction of the lacerated vessels.
From such a formidable accident, in so large a joint, there
appeared very little probability of the patient's recovery without
immediate amputation ; I therefore requested that a consultation
with some other surgeons might be expeditiously held on the case,
and expresses for this purpose were accordingly sent to Mr.
Pearson, surg-eon in London, and to my brother, Mr. Henry
Rumsey, surgeon at Chesham, in this county. While I was
waiting for their arrival, the patient requested me to examine his
thigh, when I plainly discovered an oblique fracture of the os
femoris at its superior part. This additional evil appeared to me
a great obstacle to an amputation. My brother, when he arrived,
being of a similar opinion, I attempted to reduce the fractured
dislocated joint into its proper situation. This I found very
difficult without first separating that part of the astrag-alus which
was pendulous to the tibia, having its capsular ligament lacerated
Amputation
rejected.
DISLOCATIONS OF THE ANCLE- JOINT. 291
half way around the joint. This portion of the astragalus con-
sists of the broad smooth head by which it is articulated to the
tibia; of almost the whole of the inner and outer sides of this
head, by which it moves on the inner and outer malleoli ; and of
about the upper half of the posterior cavity on its under surface,
by which it is united to the os calcis ; so that the bone Avas
divided nearly horizontally, and the part left behind consisted of
the lower half of the last mentioned cavity, of the whole of
the other or anterior cavity which connects it with the os calcis,
and of the anterior portion or process by which it is articulated
to the OS naviculare : I therefore removed it without hesitation. Removal of
being persuaded that if it had been practicable to reduce it into astragalus.
its original situation, so large and moveable a portion of bone
would have been a source of pain and irritation, and have ren-
dered the cure more difficult and uncertain. I then divided that
portion of the integuments of the foot which was confined by the
protruded end of the tibia, which enabled me with ease to reduce
it and the fibula into their proper situation. I applied some dossils
of lint dipped in tincture of opium to the wound, and covered the
whole with a poultice of stale beer and oatmeal. We now
reduced the fractured femur, and placed the limb in a bent
position, expecting that our greatest success would be in procuring
a complete anchylosis, the failure of which I concluded would
leave an useless foot. The under splint was a firm excavated piece
of deal, of the shape of the leg and foot, with a hole opposite the
ancle. Mr. Pearson arrived in the evening, and approved of the
preceding treatment, giving it as his opinion, that it would be
safer to attempt the preservation of the limb than to amputate,
P P 2
292 DISLOCATIONS OF THE ANCLE-JOINT.
under such complicated circumstances. The Avound was concealed
as much as possible from the external air, and the cataplasm
renewed no oftener than the discharge rendered necessary.
June 22nd. The preceding night had been very painful, with
Vomiting delirium and vomiting:; the pulse was full and frequent; I took
and delirium O ' r Tl '
away ten ounces of blood, and gave potassee tartras and manna in
doses sufficient to procure stools. A common saline draught, with
antimonial wine and tincture of opium, was given every four
hours, and a fuller dose of tincture of opium at bed-time.
23rd. The vomiting continued ; the ancle and thigh had
been less painful through the night; the saline draughts were
continued, but without the antimony, on account of the vomit-
ing ; during this period, the antiphlogistic regimen was strictly
adhered to.
24th. The night had been tolerable ; the vomiting had ceased ;
the pulse was softer; the saline draughts were continued, with the
opiate at bed-time ; this evening the leg was very painful ; he
passed a pretty good night ; a discharge from the wound now
commenced, and the tension of the muscles of the thigh began to
diminish.
26th and 27th. The same treatment was continued. The
discharge increased, and the tension of the thigh still more abated.
28th. The ancle was much swelled and inflamed ; I therefore
exchanged the beer-grounds in the cataplasm for the liquor
plumbi subacetatis dilutus. The patient had this day much pain
in the bowels from flatulence ; from which circumstance, and that
of the discharge being very thin, it was judged expedient to vary
his mode of living, and likewise his medicines.
DISLOCATIONS OF THE ANCLE-JOINT. 293
diet and
treatment.
29tb. He was allowed a small portion of animal food, some change of
table-beer, and some port wine; and be took tbe bark liberally,
both in substance and in decoction. This change of treatinent
agreed with him perfectly well. At this time I found it necessary
to alter the position of the limb, on account of the pressure on
the wound, occasioned by its lying in the bent position, and by
the pain caused in turning to dress it, which, from the copious
discharge, there was now a necessity for doing night and morning.
I therefore placed it on the heel, using the common deal flexible
splint, of the length of the limb, and confined it in a box, whose
sides and lower end let down; the space between the sides of the
box and splint was filled with pieces of flannel. By these means,
and the use of the eighteen-tailed bandage, the dressings were
applied with very little disturbance to the leg, and thus the
patient escaped much pain. The upper end of the box under the
ham being raised, gave the muscles some degree of flexion, and,
at the same time, was favourable to the discharge. The foot
having a tendency to fall inward, and the end of the fibula to
protrude through the wound, it required great attention to prevent
the deformity which the neglect of these circumstances might have
occasioned. The mode of prevention which I adopted, and which
proved successful, consisted in employing a number of small deal
wedges, about six inches long, two broad, and a quarter of an
inch thick ; as many of these as were found sufficient were placed
opposite the inside of the foot, between it and the side of the box ;
others, in the same manner, were placed on the outer side of the
calf of the leg ; by which means the limb was kept steady ; and
294 DISLOCATIONS OF THE ANCLE-JOINT.
by keeping the heel in an easy, and rather hollow position, none of
the usual evils arising from pressure on the heel occurred,
30th. The bark agreed very well ; the opiate was continued at
bed-time ; the discharge was great but more purulent ; the pulse
was become softer and less frequent; and the urine, which had
hitherto been clear and very high coloured, was now turbid ; the
pain and inflammation being much diminished, the cataplasm was
discontinued ; the wound was dressed with dry lint, with a pledget
of cerat. plumbi superacetatis over it, and a moderate compression
was made by means of a bandage. From this period, the wound
progressively mended ; the discharge diminished ; granulations
formed ; and the surrounding skin began to heal. The use of the
bark and of the opiate was continued till the beginning of August.
About the end of July, the progress of the cure was retarded by
Collection of matter collected under the integuments, above the inner ancle,
malter.
which on pressure came out at the wound. After in vain trying
the effects of permanent pressure for the prevention of this deposit,
I made an incision into the cavity and filled it with dry lint,
to produce inflammation on its internal surface, which consolidated
it, and the wound became perfectly cicatrised by the middle of
September, without any exfoliation of bone larger than the head
of a pin having taken place. The fracture of the femur went on
very well, excepting that its obliquity, with the impossibility of
producing a permanent extension on account of the leg, occasioned
a degree of curvature which it otherwise would not have had.
The limb gradually acquired strength, and the patient is able to
walk very well with only the aid of a small stick, and even this
DISLOCATIONS OF THE ANCLE-JOINT. 295
assistance he will probably not require long. There is no anchy-
losis to render the ancle immoveable ; but a sufficient firmness has
been produced in the surrounding parts by the long continued
inflammation to assist in the formation of an artificial joint, which
possesses a degree of motion nearly equal to that of the natural.
COMPOUND DISLOCATION OF THE TIBIA INWARDS.
For the following most interesting case I am indebted to
Mr. Hicks, of Baldock.
CASE V.
BaldocJcf August 10, \S19.
My dear Sir,
In the absence of my son, I beg leave to forward you the
following account of a case of compound dislocation of the ancle.
Case of John Curgan. Early in the morning of November 10,
1812, the Stamford coach, from the carelessness of the guard in
neglecting to chain the wheel, ran with great velocity down the
hill a mile below Baldock, and fell on its side a little before it
reached the foot of the hill; in its fall, the side of the coach
caught the coachman's right leg, and turned the foot upon the
outside of the leg, by which the tibia became dislocated on the
inner side ; the tibia and fibula protruded through the integu-
ments about four inches ; the oblong end of the fibula was
fractured, and several small portions of it remained within the
296 DISLOCATIONS OF THE ANCLE-JOINT.
integuments ; the end of the tibia had some small portions
chipped off, it appearing as if it had been ground by the. side
of the coach ; in this state he was brought to Baldock, with his
foot dangling to his leg ; the wound was very large, so much so,
that the foot appeared almost separated from the leg ; the ends
of the bone were covered with dirt.
As there was not the least chance of success in returning the
tibia and fibula within the integuments, in this state, and as the
patient was anxious for the preservation of his leg, which I like-
wise was very desirous to save, I judged it prudent to saw off
the ends of the tibia and fibula, the foot at the same time lying on
a pillow below the leg ; after removing the ends of the tibia and
fibula, I searched for the fractured portions of the fibula left within
the integuments, by introducing the fore finger of my right hand
into the wound, and found its external malleolus fractured into
several small pieces, but still adhering by its ligaments to the
astragalus. Being fearful that these shivered portions might be
deprived of the properties of life, and, that if so, they might
produce much mischief, I resolved to dissect them out, by means
of a bistoury, through the wound. Having thus removed every
fragment of the fibula, and rendered the ends of the tibia and
fibula perfectly smooth by means of a saw, not only removing
their fractured ends, but making the separation as high up as
they were stripped of their periosteum, about one inch and a
half in length, measuring from the malleolus internus, I then
returned the remaining part of the tibia and fibula that had
perforated the integuments, placing it in a straight line with
the leg ; the lacerated integuments I brought into contact, and
Removal of
the frag-
ments of the
fibula.
DISLOCATIONS OF THE ANCLE-JOINT. 297
secured them by straps of adhesive plaster ; the limb was then
placed upon a soft pillow, supported by Mr. Pott's long splints
placed on the outside of the pillow, and fastened with tapes ;
compresses of soft linen cloth were applied, and the leg* was
kept constantly wet with the diluted solution of the acetate of
lead, and the following draught was given for the first few days,
every four hours, and afterwards every six or eight, with a
regimen strictly antiphlogistic.
R. Pulv. Ipecacuanhas, c. gr. yj.
Magnes. Sulphat. sj.
Aquse Puree, six.
Menthae. siij.
Spt. iEtheris Nitros. sss. M. Ft. Haust.
Through the whole of the cure the man went on remarkably
well, and had little symptomatic fever ; pulse constantly below the
natural standard, between 60 and 70 ; skin soft and moist ; the
action of the intestines was regularly kept up by the draughts;
the integuments united by the first intention, without the least
secretion of pus. On the day seven weeks from the accident, the
patient was removed from Baldock to his residence at Hewlington,
and did not require chirurgical aid afterwards. In a few months
afterwards he paid me a visit at Baldock, walked perfectly well,
and the leg was very little shorter than the other. The last time
I saw him was by chance in April 1815, at the Bell New Inn,
about three miles below Baldock, where his coach stopped, and
he descended and ascended his box with great agility.
I am, my dear Sir,
Your's most respectfully,
George Hicks.
Q Q
298 DISLOCATIONS OF THE ANCLE-JOINT.
COMPOUND DISLOCATION OF THE TIBIA
OUTWARDS.
My friend and late dresser, Mr. Cooper, of Brentford, an
ingenious surgeon and an excellent man, sent me the following
valuable communication.
CASE VI.
Thomas Smith, aged thirty-six, by trade a painter, whilst at
work on the 28th of October, 1818, fell with a ladder to the
ground, when his leg getting between two of its steps, the foot
was dislocated inwards. The fibula was broken five inches
above the joint, the tibia was fractured from the ancle-joint
Longitudinal longitudinally about three inches ; this small piece of tibia, three
the tibia, inches in length, remained attached to the joint at the inner
malleolus, while an inch and a half of the remaining portion
of the tibia, with the extremity of the fibula, were thrust
through an opening in the integument, at, and rather ante-
rior to, the outer malleolus. I was passing at the time, and
attempted by very moderate extension to reduce the dislocation ;
this not succeeding, and finding the integuments tucked under
the protruding portion of bone, with a scalpel I dilated the
wound anteriorly and posteriorly about half an inch, and then,
by means of a metacarpal saw, removed rather more than an
inch of the tibia, and a small portion of the fibula. This dis-
location was now reduced without any difficulty. The wound
was closed by two ligatures and a few straps of adhesive plaster.
I
DISLOCATIONS OF THE ANCLE-JOINT. 299
The patient was placed on a mattress with the limb on the heel,
enveloped in an eig'hteen-tailed bandage, which was applied
just sufficiently tight to give moderate support, without pro-
ducing or increasing tension ; on either side was placed a
splint, and the limb was kept constantly cool by means of an
evaporating lotion.
Subsequent to the operation, and during the whole of the night,
there was some hsemorrhagy from the articular arteries, but not
sufficient to induce me to undo the limb in order to secure the
bleeding vessels, and I did not open it till the 31st of October,
the fourth day, when considerable adhesion had taken place, and
the parts looked better than I could have expected ; but on the
eighth day there was a line of separation formed about five or six
inches in circumference ; the wound was now fomented, a linseed
meal poultice was applied to it every six hours, and the evaporat-
ing lotion was still applied to the limb as far upwards as the knee.
On the thirteenth or fourteenth day the slough came away, and
healthy granulations were observable, both upon the integuments,
and also upon the extremity of the tibia ; when these granulations
became exuberant, they were kept down by the nitrate of silver,
and the wound was slightly dressed either with ungt. cetacei, or
equal parts of ungt. resinse and cerat. calamines. In five weeks,
the wound was perfectly healed ; the union of the fractured por-
tions of the tibia went on so well, and the ossific deposite at the
joint became so firm, that on Christmas day, being fifty-eight days
from the time of the accident, I found the man sitting at his table
dining with his family, and in three months he was in the street,
on crutches.
Q Q 2
300 DISLOCATIONS OF THE ANCLE-JOINT.
This patient had repeatedly suffered much from colica pictonum ;
his digestive organs were unhealthy, and he was a man of nervous
temperament, all which particulars I had to discover after the
accident. As early as the third day he was very restless, on the
fourth, his sensorium was much affected, and he was constantly
vomiting ; by the frequent administration, however, of the saline
mixture in the act of effervescence, his stomach was quieted.
I ought to have observed that, on the night of the accident, he
took an opiate, and on the following day I purged him ; but from
the state of his pulse, and from the degree of haemorrhagy, I did
not find it requisite to take blood from the arm. By the eighth
day, his stomach being tranquil, we were enabled to assist the
separation of the slough, by invigorating the powers of the system
with bark and port wine ; from half a pint to a pint of which, with
eight ounces of the decoction cinchonas and opium, the quantity
being regulated by his state of irritability, enabled him to support
the immense suppuration at the joint, which, from this time to
the fourth week, discharged most copiously.
I may here mention, that I never observed, on the one hand, the
stimulating effects of opium, and on the other, its sedative effects,
so strikingly exemplified as in this man ; for if he did not take
quite enough to produce sleep, he was literally mad, tearing the
bed-clothes, swearing, praying, singing, and making the oddest
grimaces possible ; but if he had a full dose, which, by the third
week, had been increased to two drachms of laudanum, he slept
soundly and awoke refreshed; and I believe from his extremely
susceptible state, that, but for opium, which produced a directly
sedative effect upon his nervous system, he would have sunk from
DISLOCATIONS OF THE ANCLE-JOINT. 301
constitutional irritation. At the end of the second week, his
stomach being in a fitter state for digestion, he was allowed a
plentiful supply of animal food and good beer, with which,
and wine, bark, and opium, continued for a week or two, he
perfectly recovered.
I am. Sir, &c. &c.
George Cooper.
I saw this man on March the 1st, 1820, and I said, " Would
you rather have your present or an artificial leg ?" — " Sir," said
he, " my injured leg is nearly as useful to me as the other ; I can
go up a ladder, and follow my business as a painter, nearly as well
as ever." A. C.
COMPOUND DISLOCATION OF THE TIBIA INWARDS.
CASE VII.
Worcester, July 30, 1819.
Dear Sir,
I have had no case of compound dislocation of the ancle-joint
under my care since I have settled in practice ; but my colleague,
Mr. Sandford, gives me the following information, which I do
myself the pleasure of transcribing.
A boy, fifteen years of age, was admitted into the Worcester
Infirmary with compound dislocation of the ancle ; the protruding
portion of the tibia was sawn off*, the anterior tibial artery was
taken up, the limb was placed on its outer side, the wound dressed
superficially, and the dressings retained with a many-tailed
302 DISLOCATIONS OF THE ANCLE-JOINT.
bandage, kept wet with the liq. ammon. acet. Suppuration and
granulation came on kindly. The boy wore tin splints for a length
of time, and on his recovery had a slight motion of the ancle-joint.
I am, my dear Sir,
Your's very respectfully,
J. Garden.
COMPOUND DISLOCATION OF THE TIBIA
OUTWARDS.
CASE VIII.
My dear Sir, Gloucester, Sept. ], 1819.
Some domestic events have delayed my reply to your letter.
I remember six cases of compound dislocation of the ancle-joint,
four of which underwent immediate amputation. In the two
other cases attempts were made to save the limbs, and in one with
success. Most of these accidents were produced by machinery ;
and the injury to the joints and soft parts was so great as to
destroy all hopes of saving the limb.
In the limb that was not saved, though the attempt was made,
there had been too much mischief done, and, after a trial of seven
months, amputation was performed.
I was called to a fine young woman, eighteen years of age, who
had been consulting me not an hour before on the case of her
father, and who having fallen from her horse, had suffered a com-
pound luxation of the ancle-joint eocternally. The tibia and broken
fibula protruded about an inch and a half through the wound on
DISLOCATIONS OF THE ANCLE-JOINT. 303
the outside of the limb. I sent her to the hospital, and in consul-
tation proposed that a sufficient quantity of the bones should be
removed to admit of restoration, I advised this attempt to save
the limb, from observing that the accident took place by a heavy
fail with the sole of the foot to the ground, that it was unaccom?-
panied by contusions or violence committed by a blow or wrench,
and that the patient was a very healthy country girl. There
had been considerable haemorrhage.
The extremities of the bones were removed, the reduction
accomplished, and the limb supported by a tailed bandage ; splints
were applied moderately tight, and the bandages were directed to
be kept constantly soaked in a cold application. An opiate was
given.
On the following day there had been considerable haemorrhage,
but the limb was not disturbed. Great suppuration took place
about the joint, spread up the limb, and greatly exhausted the
patient, but she recovered. These collections were never opened.
I should have opened them early, and thus perhaps have prevented
that extent of suppuration which so much reduced the patient.
Any further details T will give you with great pleasure if you
require them, and I must hope that on all occasions you will
make use of me ; and now accept my apology for not answering
your letter before.
Very faithfully yours,
R. Fletcher.
304 DISLOCATIONS OF THE ANCLE-JOINT.
The following I received from my friend, Dr. Lynn :
CASE IX.
A man on board the Walmer Castle, East Indiaman, in the
year 1808, whilst the ship was off the Cape of Good Hope, fell
between decks, and a cask of water rolled upon his ancle, pro-
ducing a compound dislocation of the end of the tibia inwards. I
sawed off the projecting portion of the tibia, brought the parts as
closely as possible together, applied evaporating lotions to the
limb, and the man recovered without any dangerous symptoms.
James Lynn, M.D.
ADDITIONAL CASES OF COMPOUND DISLOCATION
OF THE ANCLE-JOINT.
Leicester, June 29thf 1823.
Dear Sir,
Inclosed I send you the particulars of the case of compound
dislocation of the ancle-joint, as extracted from the hospital
books by Mr. Wilkinson, the house surgeon, to whom the
dressing of the injury belonged.
Two other cases have occurred to me in private practice,
which, although I have taken no particular notes, are valuable
in fact, as shewing that the practice is good as adopted in the
detailed case which I have sent you. The wounds in the two
cases did not heal by the first intention, and the synovial fluid
DISLOCATIONS OF THE ANCLE-JOINT. 305
was discharged for some time, yet they ultimately healed, and
did well. One of the cases, as I have since had opportunities
of knowing^, has completely recovered the free use of the ancle.
Catherine Paddimore, aged seventy-two, was admitted into the
hospital on the afternoon of September 4, 1821, from the country,
with compound dislocation of the ancle-joint. She was in the act
of picking up pears, when her husband fell from the tree, and
lighted on her back, which occasioned the accident. On examina-
tion, after removing a considerable quantity of blood, the inferior
extremity of the tibia of the right leg was protruding nearly
three inches through a laceration of the integuments ; the foot
turned completely outward ; the fibula was fractured in two places.
The patient being placed in bed on her right side, and the wound
being cleaned, the knee was flexed, and, with moderate exten-
sion, the dislocated tibia was reduced, and the fibula adjusted.
The wound was approximated with adhesive straps ; M. Dupuy-
tren's splint and bandage, and an evaporating lotion were applied.
The patient was retained on the right side, and the limb flexed :
she was very much exhausted. Her bowels were soon acted on
by the sulphate of magnesia.
September 5th. No sleep; tongue furred; pulse frequent
and strong ; bowels well opened ; no great pain of the ancle,
and trifling swelling. Fiat venesectio e brachio ad 5xx. vespere.
Pain and swelling of the ancle-joint a little increased; pulse
frequent and soft. Admoveantur hirudines No. xvi. statim.
She takes liq : ant: tart; small doses of the sulphate of mag-
nesia, with a febrile julep, every three hours.
R R
306 DISLOCATIONS OF THE ANCLE-JOINT.
September 6th. Slept several hours ; pulse frequent and
soft ; skin comfortable ; bowels not open since yesterday ; tongue
furred ; makes no complaint of the leg-, which looks remarkably
well. She repeated the sulphate of magnesia.
September 8th. No pain or swelling about the ancle-joint;
bowels open.
September 9th. The wound was dressed ; the adhesive process
far exceeded expectation ; no pain.
September 13th. Wound healing.
September 28th. Wound well.
October 4th. Allowed to sit up.
October 13th. Can walk with crutches.
She has now perfect use of the joint, and could walk very well
last summer, without crutches.
Your's very truly,
John Needham.
DISLOCATION OF THE ANCLE OUTWARDS.
William Thomas, aged eighteen, was admitted into Guy's
Hospital, June 28th, 1823, with a compound dislocation of the
ancle outwards, caused by a hogshead of tobacco falling upon
his leg.
The foot was doubled inwards, and the malleolus externus
broken, which being immediately removed, the limb was placed
upon a splint on its inner side, with the knee bent, two sutures
were applied to bring the edges of the wound together, and a
I
DISLOCATIONS OF THE ANCLE-JOINT. 30/
piece of lint placed over it ; the leg" was kept well wetted with
the liq: plumb: acet: dil. The patient was ordered to take forty-
drops tinct; opii:, and not to be disturbed.
June 29th. Ordered calomel gr. v. and an aperient draught
to be taken afterwards.
June 30th. The lint was removed from the wound, and a
poultice ordered: no febrile symptoms appearing, this treatment
Avas continued, without medicine, till July 14th.
July i5th. The opiate lotion was ordered instead of the
poultice.
July 16th, 17th. The same treatment continued.
July 18th. He passed a restless night, and had a white tongue
and quick pulse ; with inflammation and swelling of the leg ;
complained of great pain. Ordered the saline draught every three
hours.
July 25th. Matter formed along the tibia ; an opening was
made, and a large quantity evacuated ; a poultice was applied
over the opening, and the opiate lotion continued to the wound.
July 28th. It was now judged expedient to change his diet,
and his medicines : he was allowed animal food with porter ; and
bark, with ammonia, was given every six hours.
August 6th. Matter had again formed ; another opening was
made, and the same treatment pursued ; his diet and medicines
were continued as before. After this period he rapidly recovered,
and at the latter end of the month was able to rise from his bed.
The wound always looked healthy.
RR2
308 DISLOCATIONS OF THE ANCLE-JOINT.
DISLOCATION OF THE ANCLE FORWARDS.
JVew Bridge-street, BlacJcfrtars ;
March 4th, 1824.
My dear Sir,
I have much pleasure in sending you an account of the case
I mentioned to you last night, together with a sketch by which I
have endeavoured to shew the position of the limb at the time
when I saw the patient.
CASE.
James Price, aged thirty-nine, a very robust young man, was
coming to town on Monday, the 1st of March, in a light cart,
drawn by one horse. In passing through Clapham the horse ran
away, and falling, overturned the cart, and threw Price's legs
under one of the shafts; in endeavouring to extricate himself, he
received a severe injury to the right ancle. By the direction
of Mr. Parratt he was immediately conveyed to St. Thomas's
Hospital, where I saw him ; and, on examination, found that the
tibia had been dislocated forwards, and a little inwards, its inferior
extremity resting on the fore part of the astragalus and os
naviculare : the deltoid ligament must have been torn through, as
the inner malleolus was not fractured. The heel projected very
considerably, and the foot was turned outwards in a slight degree
and downwards, the toes being pointed. The fibula was fractured
about two inches above the external malleolus, at which part there
was a considerable depression. The reduction was very easily
DISLOCATIONS OF THE ANCLE-JOINT. 309
accomplished by flexing- the leg on the thigh, which was firmly
held by my dresser, Mr. Campbell, as I drew the foot downwards
and forwards, and pressed the tibia backwards. The limb was
placed in the flexed position, on the heel ; since which time the
patient has been perfectly tranquil, and the limb remains in its
proper position.
Believe me, your's most sincerely,
Frederick Tyrrell,
Surgeon to St. Thomas's Hospital.
EXPERIMENT.
I was anxious to ascertain what steps nature pursued in order
to restore a part in which the extremity of a bone, forming a joint,
had been sawed off; and I therefore instituted the following
experiment.
I made an incision upon the lower extremity of the tibia, at
the inner ancle of a dog, and cutting the inner portion of the
ligament of the ancle-joint, I produced a compound dislocation of
the bone inwards. I then sawed off the whole cartilaginous
extremity of the tibia, returned the bone upon the astragalus,
closed the integuments by suture, and bandaged the limb to pre-
serve the bone in this situation. Considerable inflammation and
suppuration followed ; and in a week the bandage was removed.
When the wound had been for several weeks perfectly healed, I
dissected the limb. The ligament of the joint was still defective
at the part at which it had been cut. From the sawn surface of
310 DISLOCATIONS OF THE ANCLE-JOINT.
the tibia there grew a ligamento-cartilaginous substance, which
proceeded to the surface of the cartilage of the astragalus, to
which it adhered. The cartilage of the astragalus appeared to be
absorbed only in one small part ; there was no cavity between the
end of the tibia and the cartilaginous surface of the astragalus.
A free motion existed between the tibia and astragalus, which was
permitted by the length and flexibility of the ligamentous substance
above described, so as to give the advantage of a joint where no
synovial articulation or cavity was to be found. This experiment
not only shews the manner in which the parts are restored, but
also the advantage of passive motion : for if the part be frequently
moved, the intervening substance becomes entirely ligamentous ;
but if it be left perfectly at rest for a length of time, ossific action
proceeds from the extremity of the tibia into the ligamentous
substance, and thus produces an ossific anchylosis.
CASES WHICH RENDER AMPUTATION NECESSARY.
Cases But Still cascs occur in which the operation of amputation will
requiring
amputation, ^e rendered absolutely necessary, either to preserve the life of the
patient, or to prevent his being doomed to the constant necessity
of using crutches on account of the deformity and stiffness of the
limb.
Does not It sccms to mc, however, to be by much too prevailing an
always sue- • • i -i . • .
opinion, that the amputation of the limb is a sure means of pre-
serving life ; for when this operation used to be more frequently
ceed
DISLOCATIONS OF THE ANCLE-JOINT. 311
performed in our hospitals than it now is, for compound disloca-
tion of the ancle and compound fracture of the leg', a considerable
number of our patients died. Very lately a man at Tring had his
foot torn off by a threshing machine, and the limb was obliged to
be amputated at the usual place below the knee. The operation
was performed by Mr. Firth, but the man died in the evening of
the sixth day ; and a case has occurred since the publication of
the second edition of my Essays of equally fatal termination.
The circumstances which I have known to create this necessity
are,
(1.) The advanced Age of the Patient.
Under great age the powers of the body become so much Age.
weakened, that the patient is unable to bear the constitutional
excitement which the suppurative inflammation of the joint
produces ; and as amputation does not expose him to this process,
it is better to have recourse to that operation. However, 1 ought
to observe, that when in my lectures I have stated what I have
now advanced, the pupils have flocked around me after lecture,
and have told me of cases of recovery, even of very old persons ;
but in the practice of hospitals in this great metropolis, very aged
persons sink under these accidents, if the limb be not amputated.
(2.) A very extensive, lacerated JVound will give rise to a
necessity for this Operation.
CASE I.
July 10th, 1806, Mr. Dudin, a gentleman residing in Horsley- Laceration.
312 DISLOCATIONS OF THE ANCLE-JOINT.
down, Borough, jumped out of his one-horse chaise, and dislo-
cated the tibia inwards at the ancle, through a large lacerated
wound, and a portion of the malleolus internus was broken off and
remained attached to the astragalus. The wound bled freely,
and the foot was loose and pendulous ; I therefore felt myself
obliged to amputate the limb.
Mr. D., after this operation, proceeded in every respect
favourably ; recovering without any untoward symptom.
CASE TI.
James Morrise, aged thirty-six, was admitted into St. Thomas's
Hospital, on the 29th of January, 1824, under the care of Mr.
Green, having sustained a dislocation of the ancle-joint, in con-
sequence of having his leg caught in the coil of a rope, to which
a great weight was appended.
The injury was accompanied with so much loss of integument,
that immediate amputation was proposed, to which the man would
not give his consent. Mr. Green sawed off the end of the bone
and replaced the tibia upon the astragalus ; but the end of the
tibia, from deficiency of skin, still remained exposed. The con-
stitutional and local irritation which followed, rendered it necessary
to amputate the limb, which was done on March the 19th, being
seven weeks and one day after the accident. With Mr. Green's
permission I then dissected it, and the following is the result.
Dissection,
The cellular membrane was loaded with serum ; all the muscles
remained in a sound state, but the tendon of the tibialis anticus
I
DISLOCATIONS OF THE ANCLE-JOINT. 313
was partially toriij as was that of the peroiieus tertius ; those of
the tibialis posticus, and flexor loiigus digitorum pedis, adhered
strongly to the posterior portion of the capsular ligament. An
abscess extended between the tibialis posticus and gastrocnemius
muscles from the ancle nearly to the place of amputation. The
arteries and nerves were undivided, but the anterior tibial artery
was greatly diminished by the altered position and pressure of the
tibia. The deltoid ligament, the anterior part of the capsular,
and the ligament of the tendon of the tibialis anticus, were torn
through. The fibula was broken four inches from the ancle-
joint ; its lower fractured extremity overlapped the upper about
an inch, and the latter was situated between the lower portion of
the fibula and the tibia. The bones were not completely united,
and the fibula was exfoliating at the upper end of the lower
portion; apart of the fibula also remained detached, which had
been broken off at the time of the accident. The lower end of
the tibia was dead and exfoliating, and rested but partially upon
the astragalus : its periosteum was much thickened above the
exfoliating part. The outer posterior portion of the tibia next
the fibula was broken off, and strongly adhered to the fibula.
The surface of the astragalus was in parts deprived of its carti-
lage by ulceration.
The exposure and consequent exfoliation of the tibia, the exfo-
liation of the fibula, and the large abscess, led to the necessity
for amputation.
s s
diiction.
shattered.
314 DISLOCATIONS OF THE ANCLE-JOINT.
(3.) A difficulty in reducing the Bones has been considered
as a reason for Amputation,
Difficult re- This circumstance, however, is rather a motive for removing
the extremities of the bones by the saw than for performing
the operation of amputation, after which the reduction of the
tibia is easily effected, and an useful limb is preserved to
the patient.
(4.) The hones are sometimes extremely shattered.
Bones If thc lowcr cxtrcmity of the tibia be broken into small pieces,
the loose portions of bone ought to be removed, and the end of
the tibia be smoothed by a saw ; but if, in addition to this com-
minution, the lower extremity of the tibia be obliquely broken, and
a large, loose portion of bone be felt with the fingers, then it will
be proper to amputate; also, if the astragalus be broken, the
portions of this bone should be removed, otherwise they will sepa-
rate by ulceration, or occasion considerable local irritation. (See
Dr. Lynn's and Dr. Rumsey's cases.) But if the end of the tibia
and tarsal bones, as the astragalus and os calcis, are broken, then
amputation will be required. The following case shews well the
necessity of the operation in such a state of parts.
CASE.
I was requested to see a lady, aged thirty-four years, who, on
August the 9th, 1819, had, in a fit of insanity, jumped out of a
two pair of stairs window, and produced a compound dislocation
of the tibia and fibula at the outer ancle. At the lady's residence
I met Mr. Stephens, a surgeon residing in Hunter-street, Bruns-
DISLOCATIONS OF THE ANCLE-JOINT. 315
wick-square, who had been called immediately after the accident.
As she appeared almost insensible, and Mr. Stephens feared an
injury to the brain, he took away twelve ounces of blood. When
he examined the ancle, he found the malleolus externus of the
fibula projecting through the wound, but unbroken, the tibia
dislocated and broken, and the foot very much turned inwards.
He extended the foot, and thought that the bones had exactly
returned into their natural situation ; adhesive plaster was applied
upon the wound, and its edges nicely adjusted. She was placed
on a mattress with the limb upon the heel, and with a splint on
each side of the leg. For seven days she complained of little
pain, and had but slight constitutional disturbance ; on the day
week from the accident, I was requested to see her, and finding
little local or constitutional irritation, I recommended that the
limb should not be disturbed, and the dressings were not removed.
On the 10th day from the accident, Mr. Stephens finding her
in more pain examined the wound, and found that it had not
adhered.
On the 12th day, a considerable discharge issued from the
wound.
On the 16th day a slough had separated and exposed the bones,
which appeared shattered and projecting. On this day I again
saw her, and upon examining the ancle found the astragalus
projecting, and a portion of it broken ; and as the surrounding
parts were dead I removed the projecting bone. Introducing my
finger into the wound as soon as the astragalus had been sepa-
rated, the tibia was found to be shattered, and the os calcis broken
into many pieces. As her pulse was 100 and small, and her
S S2
316 DISLOCATIONS OF THE ANCLE- JOINT.
strength was failing, I immediately recommended her to submit
to the operation of amputation, to which she consented.
On the Monday following, the stump was dressed by Mr.
Stephens, and the greater part was adhering.
Two of the ligatures separated on the 10th day, and the other
came away on the 16th day.
September 29th. The stump was healed, excepting about the
size of the section of a pea, and she had no complaint remain-
ing excepting a sore upon her back, and pain in her left foot.
It is proper to mention that she hurt her spine and kidneys by
the fall, so as to discharge urine tinged with blood for three
weeks after the accident.
The other ancle also was most severely injured, and she suffered
exceedingly from pain in it.
Upon examination of the amputated limb, the tibia was split up
from the malleolus internus to the extent of three inches ; the
fibula was unbroken ; the astragalus was broken and detached ;
and the os calcis was fractured into several pieces.
I have lately had another case of the same kind in which I
was obliged to amputate. (See plate.)
(5.) The Dislocation of the Tibia at the outer Ancle,
Dislocation Produccs much more injury and danger than that at the inner,
outwards.
and amputation will be more frequently required for it, because
both the bones and soft parts suffer more than in the dislocation
inwards.
«
DISLOCATIONS OF THE ANCLE-JOINT. 317
(6.) It sometimes happens that when the Bone is replaced it
will not remain in its Situation, and all the Symptoms of
the Injury become renewed.
This circumstance arises when the tibia in the dislocation out- obUque
I'll" 111 11 11 fracture with
wards is obliquely broken, and only a small portion of the articu- dislocation.
lating' surface remaining- on the dislocated extremity of the tibia,
it will not rest on the tibia when it is reduced.
Mr. Andrews, of Stanmore, and Mr. Foote, of Edgeware,
consulted me on the following case.
CASE.
Mr. Andrews and Mr. Foote were sent for on August the
9th, 181 7j to the Hyde, six miles from London, to visit Charles
Tomlin, a higgler, forty-eight years of age, who, falling in a
state of intoxication, the wheel of his cart passed over his left leg,
and produced a protrusion of the bones through the integuments
at the outer ancle. Mr. Andrews, reduced the dislocation in the
evening of the accident. On the same night, Mr. Andrews and
Mr. Foote having visited him again, found his pulse very quick,
and spasms in the limb, which had again displaced the bone.
They gave him a large dose of opium, and succeeded in reducing
the bones.
On the 10th, he had a very quick pulse, accompanied with
strong spasms in the limb, but not sufficiently severe to displace
the bone.
On the 1 Ith, I was requested by Mr. Andrews, and Mr. Foote,
as I was going through the village, to stop and see this man ; and
318 DISLOCATIONS OF THE ANCLE-JOINT.
as soon as the bandages were removed, a violent spasm threw the
bones from the astragalus, and all the efforts I could make would
not replace them. Seeing, therefore, no hope of the man's reco-
vering without the amputation of the limb, I immediately proposed
it, and he readily gave his consent.
For three or four days he had a great deal of nervous irritation,
which was most effectually relieved by occasional doses of opium
and aether.
On the 18th the stump was inflamed, and in some parts
sloughy ; and on the 22nd it bled profusely.
On the 25th a poultice was applied ; and from this time the
appearance of the stump improved, and he proceeded without
interruption in his recovery. In a month he returned to his home
at Bushey, a distance of seven miles.
Upon examination of the limb, I found the cellular membrane
around the ancle loaded with extravasated blood ; the ligamen-
tum annulare tarsi was torn. The muscles were all remaining
whole, though some of them, as the peronei, were much put upon
the stretch. The fibula was broken one inch above the lower
extremity of the malleolus externus, which remained in its place,
still united by its ligaments to the tarsus. The tibia was split
down from two inches above the joint, leaving the greater part of
the articulating surface still resting upon the astragalus; but the
remaining portion of the articulating surface, with the shaft of
the tibia and the fibula, passed through the wound at the outer
ancle. If, therefore, the bone had been again returned to its situ-
ation, it could not have remained there, from the small portion of
DISLOCATIONS OF THE ANCLE-JOINT. 319
articulating surface attached to it; and if the projecting portion
had been removed by the saw, it would not have adapted itself to
the portion of the tibia which remained attached to the astragalus.
(7.) Tlte division of a large Blood - F'essel might, ivith an
extensive TVoiind of the Integuments, lead to a necessity for
Amputation;
ion of
But I should not, on that account, at once proceed to the opera- oi'-isi
•■ ■'■an artery,
tion. The case from Mr. Sandford, of Worcester, sent me by
Mr. Garden, clearly shews that the division of the anterior tibial
artery does not, if it be well secured, prevent the patient's reco-
very. I also once saw a compound fracture close to the ancle-
joint, accompanied by a division of that artery ; yet, although the
patient was in the hospital, and being a brewer's servant possessed
the worst constitution to struggle against severe injuries, this man
recovered without amputation.
The posterior tibial artery is a vessel of more importance, and
is accompanied by a large nerve, which would not be likely to
escape injury when the artery was divided by the dislocated bone.
Yet the magnitude of the anterior tibial artery, and its free anas-
tomosis with the posterior, would not entirely preclude the hope of
preserving the foot under an injury of the posterior tibial artery.
(8.) Mortification of the Foot
Sometimes ensues, and becomes a sufficient reason for amputating Gangrene.
the limb ; but this must be generally done when limits appear to
be set to the extension of the mortification. However, it may be
observed, that in the mortification which ensues from the division
320 DISLOCATIONS OF THE ANCLE-JOINT.
of a blood-vessel, where the brachial artery had been divided, and
the elbow-joint dislocated, I have seen the arm removed above the
injured part, whilst the limb was still dyin^ towards the seat of
the wounded artery, and the patient was restored to health. And
I have also known a case of popliteal aneurism, in which the
artery and the surrounding- parts were so compressed by the
swelling, that mortification began at the foot, and was extending*
to the knee ; and, although no limit was yet set to the mortifi-
cation, the limb was amputated, and the patient recovered. So
that mortification, when it arises from injury to a blood-vessel, or
other local injury in a healthy constitution, admits of a practice
different from that which is pursued in mortification arising from
constitutional causes.
Contusion.
Excessive Contusion may he another reason for imputation;
And, therefore, in those cases in which heavy laden carriages pass
over joints, and bruise the integuments so as to occasion the form-
ation of extensive slough, and produce at the same time, generally,
the worst examples of compound dislocation, in regard to the state
of the bones, I should immediately amputate ; for such cases are
very different from those which are caused by jumping- from a
considerable height, from a carriage rapidly in motion, or by a
fall in walking- or running-.
EMensive Suppuration ivill also be a reason for Amputation.
Suppuration. J have kuowu, after an attempt to save the limb, the patient
have more extensive suppuration than his constitution could
support, followed by an ulceration of the ligaments, by which the
DISLOCATIONS OF THE ANCLE-JOINT. 321
joint became additionally exposed, and the bones were again dis-
placed ; hence there arose an absolute necessity to remove the
limb for the preservation of his life.
(9.) A necessity for Amputation may he also produced by
Exfoliations of Portions of Bone,
Which, locked in the surrounding parts of the bone, are incapable Exfoliation,
of becoming' separated, and thus keep up a state of continued
irritation. My friend, Mr. Hammick, had the kindness to send me
a specimen of this kind, which he was obliged to amputate. The
loose portion of bone was seated between the lower extremity of
the tibia and fibula, and reached to the ancle-joint; both the bones
had been broken, and had become reunited, and the uniting
medium had inclosed and incarcerated the dead portion of bone.
It is probable, from the appearance of the parts, that this portion
of bone never would have been able to escape from the place in
which it was locked. (See plate.)
(10.) Excessive Deformity of the Foot
Will also give rise to a necessity for amputation ; and this Deformity.
deformity will take place in three directions. First, when the
foot is suffered to turn outwards, whilst the leg is placed upon
the heel, in the dislocation inwards. Secondly, when it is turned
inwards; and thirdly, when the foot remains pointed. The first
is best opposed by placing the leg upon its outer side, when that
is compatible with the treatment of the wound ; in the second
case it is best to keep the foot on the heel ; and in both cases,
splints, having a foot-piece both on the inner and outer side of
T T
;322
DISLOCATIONS OF THE ANCLE-JOINT.
the foot, must be applied: the third requires similar splints, and
a tape, as a stirrup, placed under the foot, and fastened to the
splint on the fore and middle part of the leg- to keep the foot
supported ; and the splints should be so padded as to preserve
it in its proper direction. (See plate.)
The following" case from Mr. Norman, of Bath, shews the neces-
sity for amputation, when great deformity is permitted to occur.
CASE.
I was sent for to Bradford, some years since, to amputate a leg
directly after an accident of this kind. I found the lower extremity
of the tibia, with the astragalus loosely attached to it, projecting
at the inner ancle. The wound was not large, and the soft parts
were little injured. I removed the astragalus, and reduced the
tibia, leaving it to rest upon the os calcis. I did not again see my
patient during the healing of the wound ; I believe it got well
without any severe symptoms, but the os calcis became drawn up
against the posterior part of the tibia, to which it firmly united,
and the foot became immoveable, with the toe pointed downwards.
In this state he came to Bath two years afterwards, when I
amputated the leg, and the patient did well.
Bath, August ^ndi 1819. George Norman.
(11.) Amputation has been recommended in those Cases in which
Tetanus occurs after this Injury, •>
Tetanus. Of tctauus I havc sceii one case from compound dislocation of
1
DISLOCATIONS OF THE ANCI/E-JOINT. 323
the ancle, and have heard of another. That which I saw was in
a Mr. Yare, stable-keeper, who had a compound dislocation of the
tibia inwards, and in whom I reduced the bones, and placed the
limb on its outer side. For a few days he proceeded without any-
alarming- symptoms. The only circumstance in which his case
differed from what I expected was in the slight inflammation
which succeeded upon the joint, for the restorative process seemed
to be scarcely established in him. When I paid him my morning
visit, several days after the accident, he said, " Sir, I believe I
have caught cold, for my neck is stiff";" and as he said this, with
his lower jaw raised and his teeth closed, I begged him to shew
me his tongue, to ascertain if his jaw was locked ; and he tried to
open his mouth, but was unable to do so. 1 then desired that
Dr. Relph might see him, who did all that his mind could suggest
to arrest the progress of the symptoms, but unsuccessfully, as the
different muscles of volition became affected in the back, the
extremities and the abdomen, until he was exhausted by irritation.
To amputate under such circumstances would be most unjusti-
fiable, as far as the experience of cases in this climate will enable
me to form an opinion. I have not seen amputation performed
for compound dislocation of the ancle, but I have seen it performed
for compound fracture just above the joint, and it seemed to me to
precipitate the fatal event. I have also known, in one case, the
finger amputated for tetanus arising from injury to it, yet the
patient died; and I have also heard of a third case in which it
was practised, but still the issue was fatal. There is a species of
chronic tetanus^ which sometimes even succeeds wounds, and which
will occasionally subside, and, apparently, the patient recovers,
T T 2
irritable.
^'^24 DISLOCATIONS OF THE ANCLE-JOINT.
although little be done by medicine, and nothing by surgery;
in such cases it would not be justifiable to amputate. If any
medicine be efficacious, submurias hydrargyri, with opium, is that
under which l have seen the majority of these cases recover : and
opium should also be applied to the wound.
(12.) Jl very irritable State of Constitution
Constitution ^^\\\ somctimes render all treatment unavailing to save the limb,
and will now and then prove destructive, even if the operation be
performed. There are some persons originally constituted with
so irritable a system, that the slightest injuries will destroy them.
There is a much greater number whose constitutions, originally
good, have been so much injured by excess, by want of exercise,
by over exertion of mind, by drinking freely of spirits and eating
but little, that to them the slightest accidents prove fatal.
CASE.
One of the most curious examples of this kind which I have
seen was in a man who worked at Barclay's Brewhouse, in the
Borough. The circumstances were these :
On Saturday he was turning a cask, and a splinter of wood
entered his thumb, which he immediately drew out.
On Sunday night he requested his wife to rise and make him a
poultice ; for his thumb, he said, Avas painful.
On Monday he sent for Mr. John Kent, surgeon in the
Borough, who found his thumb inflamed and painful.
On Tuesday the inflammation had extended to the hand and
fingers.
DISLOCATIONS OF THE ANCLE-JOINT. 325
On Wednesday a swelling' appeared at the wrist, above the
ligamentum annulare carpi, and the man had a great deal of
irritative fever, and was obliged to keep his bed.
On Thursday, after lecture, Mr. Kent came to me, requesting
I would see this man, who had been delirious during the night ;
his arm being much convulsed, and his body becoming generally
so. I went with Mr. Kent, and feeling the thumb, discovered a
fluctuation in the theca. I put a lancet into the extremity of the
thumb, and a considerable quantity of pus issued. Gratified with
the expectation of his being relieved by the discharge of the
matter, I was going out of the room to express this feeling to his
friends, when I heard a rustling on the bed behind me ; and upon
Mr. Kent and myself turning back, we saw him under the influence
of a convulsive fit, which raised him in his bed, and in which he
fell back and expired.
Living as these persons generally do, principally upon porter
and spirits, they have constitutions which render them the worst
subjects for accidents.
The following case shews the violent symptoms and quick
dissolution which will, from the same cause, occasionally ensue
in compound dislocation of the ancle.
•
CASE.
On June the 10th, 1809, I was requested to go immediately
to Gracechurch-street, to see a Mr. Fenner, who, in walking
opposite to the City of London Tavern, had slipped from the foot-
326 DISLOCATIONS OF THE ANCLE-JOINT.
way and produced a compound dislocation of the ancle. The
tibia projected at the inner ancle ; the fibula was broken ; and
the skin was tucked in under the extremity of the tibia.
First : I immediately procured a mattress for him, instead of a
feather-bed.
Secondly : A many-tailed bandage ; splints lined with wool ;
and pillows and tapes.
Thirdly : The skin was divided, and the bone reduced ; but
it was much opposed by violent spasm of the muscles.
Fourthly: The edges of the wound were closely adjusted.
Fifthly : The bandage and splints were applied ; and the limb
was placed upon pillows on its outer side, with the knee bent.
Sixthly: Bled to 145, and opium given ; tinct. opii. gtt. xxx.
June 11th. His night had been restless; his tongue was
white; his pulse beat 110 strokes in a minute; he had violent
pains in the ancle, and had vomited. Ordered oleum ricini, as
his bowels had not been relieved. Evening : he had almost
constant spasms of the muscles of the leg; he had not slept,
and had no appetite. The oleum ricini had produced four
evacuations.
June 12th. His pulse was 120; his tongue more furred. He
had violent and very frequent spasms. He had nausea, but had
not vomited since the last report. He had had one evacuation.
Blood, was extravasated about the ancle; and a sanious serum
was discharged from the wound. Ordered opium.
June 13th. Had slept three hours. There was some inflam-
mation about the wound, and swelling of the leg, with spasms,
but they were less violent than yesterday. A poultice was applied
DISLOCATIONS OF THE ANCLE-JOINT. 327
to the ancle, and fomentations ordered. Pulse 120; his tongue
was very much furred. Evening : in most violent pain ; he was
ordered submurias hydrargyri five grains, with two grains of
opium, and the saline medicine with antimony.
June 14th. The spasms continued, but the pain had in a
great degree ceased. He had had several evacuations, but had
been delirious during the night. The limb was but little swollen ;
the foot appeared slightly inflamed, but there was no healthy
discharge, nor any granulations beginning to form. The former
treatment was ordered to be continued.
June loth. He had passed a bad night, being delirious
through a great part of it. He had a violent spasm in the
limb this morning, which produced a slight haemorrhage, which
was stopped by pressure. His leg was swollen, and the wound
appeared to be without action. His pulse was equally quick,
and he took no nutriment.
June 16th. He had spasms in the thigh of the same side,
and in the other leg, as much as in the injured limb; in other
respects he remained the same.
June 17th. He was delirious during the previous night, and
bleeding was again produced by the violence of the spasms. His
pulse was considerably quicker than before.
June 18th. He died at four o'clock in the afternoon.
Persons who are much loaded with adeps are generally very
irritable, and bear important accidents very ill ; indeed they
frequently perish, whatever plan of treatment be pursued : to this
328 DISLOCATIONS OF THE ANCLE-JOINT.
statement, however, there are exceptions in those who, though
Corpulent corpulcnt, are still in the hahit of taking much exercise, as they
persons. •■• o j
will retain some vig^our of constitution ; and in such persons the
limb may be attempted to be saved, as in the case described by
Mr. Abbott, surgeon at Needham Market ; but in those who
have become extremely fat, and who have been addicted to
habits of indolence, there is but little chance of preserving life
but by amputation.
Having thus endeavoured to explain what has fallen under my
own observation, and what I have been able to learn from others
upon this difficult subject, I beg leave to express a hope, that
any of my friends, who may have had cases under their care
which would throw further light upon the subject, will have the
Invitation to kiuducss to couimunicatc them to me, whether they make for or
correspond-
sub>ct""'^ against the advice that I have given, as I have no further wish
but that all the points respecting this severe accident may be
fully elucidated and established ; and shall only add, that the
observations which I have made in favour of saving the limb in
compound dislocations of the ancle-joint, will apply much more
strongly in country practice than in that of the large hospitals
in London.
The jlncle is sometimes dislocated hy Ulceration.
Sept. 23rd, 1823. With Mr. Dixon, surgeon of Kennington,
I visited Mr. P., a patient of his, who had a dislocation of the
ancle produced by ulceration. An ulcer existed at the inner ancle,
which had discharged synovia. The ancle-joint was red and
DISLOCATIONS OF THE ANCLE-JOINT. 329
greatly swollen, the foot drawn outwards by the action of muscles,
and the internal malleolus thrown inwards upon the astragalus.
The tibial arteries were greatly stretched ; and the fibula, by its
pressure on the malleolus externus, produced considerable and
constant pain. Mr. P. is a very old man, and dying of the
disease.
u u
FRACTURES op the TIBIA and FIBULA
NEAR THE ANCLE-JOINT.
the fibula.
Fracture of The fibultt Is frequently broken from two to three Inches above
the ancle-joint, and the patient instantly becomes conscious of the
accident by feeling" a snap a little above the outer ancle ; by the
pain which he suffers in his attempt to bear upon the foot ; by his
inability to place his foot flat upon the ground, resting it rather
on the inner side to throw the bearing* of the body upon the
tibia ; and by pain and a sensation of tnotlon at the injured part
when the foot is bent or extended. The surgeon discovers the
nature of the accident by rotating the foot with one hand, and
by grasping the lower part of the leg with the other ; at each
rotation a crepitus is g-enerally felt. There is also frequently an
inequality of the bone at the broken part, which assists in pointing
out the nature of the Injury.
The cause of this injury Is a blow upon the inner side of the
foot, or some violence which forces it outwards against the lower
extremity of the fibula ; and I have known it broken by distortion
of the foot inwards. A fall laterally, whilst the foot is confined
Its cause.
FRACTURES OF THE ANCLE-JOINT. 331
in a deep cleft, produces this accident. I broke my right fibula
by falling" on my right side whilst my right foot was confined
between two pieces of ice, and I could with difficulty support
myself to a neighbouring house by bearing upon the inner side of
my foot. I went home in a carriage, and every jolt of it gave me
pain at the fractured part as I suspended my leg upon my hand.
I knew that the bone was broken by the severe snap which I felt
in the part at the moment of the accident.
The treatment which this injury requires is, to apply a many- its treat-
tailed bandage upon the limb, and to keep it wet with a lotion of
spir. vini. s aquae i v. ; to apply a splint, with a foot-piece on
each side, padded with cushions in such a manner as to preserve
the great toe in a line with the patella, an invariable rule on these
occasions ; and to place the leg upon its side in the semiflexed
position, so as to relax the muscles, and render the patient's
position as easy as possible.
A want of attention to the treatment of this accident leads to Lameness
from negr
permanent lameness. Dr. Blair, a naval physician in the American '^•=*-
war, informed me that he found great difficulty in walking the
streets of London on one side of the way, but upon the other he
walked better than on flat ground ; and when I remarked his
lameness, and inquired into its cause, he informed me it had arisen
from a fracture of the fibula, which happened many years ago ;
and to which not having applied splints, the foot became twisted,
so that he walked better upon an inclined plane than upon flat
ground.
u U 2
332
FRACTURES OF THE ANCLE-JOINT.
FRACTURES OF THE TIBIA AT THE ANCLE-JOINT.
Fracture
of the tibia.
Diagnosis.
Treatment.
Oblique
fractures.
Treatment.
The tibia is often broken into the ancle-joint, or through the
bone a little above it ; and these fractures pass either obliquely
inwards, or obliquely outwards : the first in a line from the usual
seat of fracture of the fibula, that is, from one to two inches
above the external malleolus to the inner ancle : the second from
one to two inches of the tibia above the ancle, downwards and
outwards into the joint.
The first is distinguished by crepitus at the ancle when the foot
is rotated, bent, or extended ; and by a slight inclination of the
foot outwards. If the fracture does not enter the joint, but
obliquely crosses the tibia above it, the lower part of the tibia
slightly projects over the malleolus internus.
The treatment in this case consists in using evaporating lotions;
the many-tailed bandage ; splints with a foot-piece to each, padded
so as to incline the foot inwards, and to bring the toe into its
natural line with the patella, which is easily effected with the
splints to which I have alluded.
The symptoms of the oblique fracture of the tibia downwards
and outwards into the joint are, as in the former case, a crepitus
upon rotation, flexion and extension; but the foot is slightly
inclined inwards, and the malleolus externus projects more than it
naturally would. The same bandages and splints are to be used
as in the former case ; and the position in both these accidents
should be as follows :
The leg should be raised so as to bend and elevate the knee;
and the limb should rest upon the gastrocnemius muscle, and
FRACTURES OF THE ANCLE-JOINT. 333
upon the heel. The splints will support the foot on each side,
and the \eg should be supported by a pillow, reaching from the
knee to beyond the foot, secured by tapes around it. I have seen
both these cases do well when the patient and his leg rested upon
the outer side ; but the advantage of placing the limb upon the
heel is, that it gives the surgeon an opportunity of observing the
least deviation in the line of the foot, relatively to the axis of the
leg ; and this is also an easier position to the patient.
The outer portion of the lower extremity of the tibia, at the Dislocation
part at which it joins the fibula, is sometimes fractured and split ftomfiae-
off from the shaft of the bone in jumping from a considerable
height : the foot then rises between the tibia and fibula ; a
dislocation of the tibia inwards is produced, and the foot is
elevated between the two malleoli. The treatment required in
this case is the same as in the dislocation inwards.
Oblique compound fractures into the ancle-joint generally do obiique
well if care be taken to produce adhesion of the wound, which fractures.
is to be effected by applying lint, embued in blood, to the lacerated
skin, and by leaving it there until it separates spontaneously. The
same bandages and splints are required as in simple fractures,
but the position must be varied according to the situation of the
wound. Even if suppuration occurs the patient will generally
recover, unless he be much advanced in years.
But if, with compound fracture into the joint, there be much
comminution of bone, and hsemorrhagy from any large vessel, it
will be proper to amputate immediately, more especially if the
patient be obliged to obtain his bread by his labour ; for after
recovery, under great comminution, the limb will bear but slight
exertion.
DISLOCATION of the TARSAL BONES.
Junction
with other
bones.
Simple
dislocation.
SIMPLE DISLOCATION OF THE ASTRAGALUS.
The astragalus is connected above and on each side with the
tibia and fibula by its trochlea ; below it has articulatory surfaces
for its junction with the os calcis, to which it is united by means
of a capsular and strong interosseous band of ligament; and
anteriorly to the os naviculare, by a capsular, broad, and internal
lateral ligament. A simple dislocation of the astragalus some-
times, though rarely, occurs ; a compound luxation is still more
rare.
A simple luxation of the astragalus is a most serious accident,
being very difficult to reduce ; and should the reduction not be
effected, the patient is ever after doomed to a considerable degree
of lameness.
CASE I.
Being sent for into the country to visit a patient, the surgeon,
DISLOCATIONS OF THE TARSAL BONES. 335
Mr. James, of Croydon, whom I met there, requested me to see
a gentleman who had a dislocation of the foot, which had hap-
pened several weeks before, but had not proceeded to his
satisfaction. Upon examination, I found the astragalus dislocated
outwards, and the tibia broken obliquely at the inner malleolus.
Every attempt to reduce it was made which Mr. James, who is
an extremely well-informed man, could adopt; five persons kept
up a continued extension when the accident first happened, but
without effect ; the patient was then taken home, and several
persons were employed in extending the foot, and it was thought,
after a time, with some success ; but the reduction could not, by
all their efforts, be rendered complete, as the astragalus still
remained projecting upon the upper and outer part of the foot.
The extension could not be carried further ; the integuments
sloughed from that which had been already made : and the wound
was a long time in healing. The limb now deviates much from
its natural shape ; the toes are turned inwards and pointed
downwards ; there is some little motion at the ancle, and only a
slight degree of it between the projecting and raised astragalus,
and the other bones of the tarsus.
This accident, then, is of a most serious nature ; for the gentle-
man in question had placed himself under the care of a most
intelligent and persevering surgeon, and yet the attempts which
he made at reduction were not successful ; merely from the
nature of the accident, and not from any fault in the means
which were pursued. In these cases the use of puUies will be
required, and the action of the muscles should be lessened by
tartarized antimony. (See plate.) ^ ^
.336 DISLOCATIONS OF THE TARSAL BONES.
I attended the following case with my friends, Mr. West, sur-
geon of Hammersmith, and Mr. Ireland, surgeon in Hart-street,
Bloomsbury. It is highly interesting and instructive ; and shews
most clearly the necessity that surgeons should be upon their
guard in amputating limbs, and in performing operations, as the
resources of nature are sufficient, under very formidable cir-
cumstances, to effect restoration.
CASE II.
On July the 24th, 1820, ]Mr. Downes had the misfortune to
dislocate the astragalus by falling from his horse. The accident
happened at Kinsal Green, about six miles from London ; and Mr.
West, surgeon at Hammersmith, who was called in to him, made
an attempt to reduce the dislocation, which could not be effected.
The patient was largely bled ; the limb was placed in splints ;
Goulard's lotion was applied, and an anodyne given. The patient
felt great pain, and a sense of pressure against the skin and
ligaments, on the evening of the accident. A purge was directed
to be given, and anodynes occasionally in saline draughts.
On the following day, the 25th, Mr. Ireland, who had visited
Mr. Downes the evening before, called upon me, and requested
me to accompany him to see the patient, and to meet Mr. West.
When I examined the limb I found the astragalus dislocated
forwards and inwards ; and the fibula appeared to be broken a
little above the joint. I made an attempt to reduce it, but found
the bone immoveably fixed in its new situation, projecting so as to
make the nature of the case perfectly clear, and bearing so
strongly against the skin that a slight incision would have exposed
DISLOCATIONS OF THE TARSAL BONES. 337
it. My first impression was, that I ought to dissect away the
astrag-alus ; but aware of the resources of nature in accommo-
dating parts under luxations, and in restoring the limb to useful-
ness, I observed to Mr. West, and to Mr. Ireland, that I would
not operate, and that perhaps the skin might give way, and the
bone become exposed, when we should be justified in removing it.
The previous treatment was continued.
On the 26th he had some irritative fever, when the saline
medicine with antimony was given.
On the 28th there Avas considerable local irritation, and leeches
were applied.
On the 29th the leeches were repeated and the lotion continued.
On August the 10th the skin began to be disposed to slough,
opposite the projection of the astragalus at the inner ancle.
On the 14th, fomentations and a yeast poultice were directed
to be applied, and bark and wine were given.
On the 16th the skin sloughed.
On the 20th there was a great discharge of pus, and the astra-
galus became exposed. The same means were continued ; and
the inflammation and discharge gradually lessening, the wound
was dressed with lint and adhesive plaster.
The astragalus gradually became dislodged ; the ligament
sloughing or ulcerating. In September, the patient was able
to be removed to London.
On October the 5th, 1820, I again saw him, and finding the
astragalus very loose, removed it with forceps, dividing only some
slight ligamentous adhesions. The bleeding was trifling, and
was suppressed by the application of lint alone.
XX
338 DISLOCATIONS OF THE TARSAL BONES.
In December some slight exfoliations occurred, which produced
pain and inflammation ; but at the end of the month he began
to walk.
After the astragalus was removed, soap plaster was applied ;
and Mr. Downes gradually recovered his strength, and was able
to walk without the aid of a stick.
In October, 1821, he had slight motion at the ancle, which has
been gradually increasing. (^See plate.) ^-^ '-'
COMPOUND DISLOCATION OF THE ASTRAGALUS.
CASE L
In the first case of this accident which I had an opportunity of
witnessing, the astragalus was thrown inwards and forwards upon
the OS naviculare ; and when I afterwards saw the limb upon the
table of the dissecting room, it having been removed by amputa-
tion, I exclaimed, surely that limb might have been saved.
CASE IL
In the case of which an account was sent me by Dr. Lynn, of
Bury St. Edmunds, it will be seen that the discharge of the
astragalus, in a compound dislocation of the ancle-joint, did not
prevent the patient's recovery; for he says, "In five weeks a
portion of the astragalus separated, and another piece a week
afterwards, which, when joined, formed the ball of that bone."
DISLOCATIONS OF THE TARSAL BONES. 339
CASE III.
Mr. Trye, of Gloucester, had also under his care a case of
compound luxation of the astragalus, in which he cut out the
luxated bone, and the patient had a good recovery, with a
tolerably useful foot.
The following case was under the care of Mr. Henry Cline, in
St. Thomas's Hospital :
CASE IV.
Martin Bentley, aged thirty years, Avas admitted into St.
Thomas's Hospital at twelve o'clock at noon, on June 21st, 1815.
He had just before been overpowered by some stones which he
was endeavouring to sling into a ship's hold, by which he was
knocked down, and which fell upon him, occasioning a compound
fracture of the tibia and fibula of the left leg, near the middle,
with a dislocation of the astragalus of the other foot, from the
other bones of the tarsus.
As there was much laceration of the skin and muscles, Mr. H.
Cline thought it right to amputate the limb below the knee, which
was done about three hours after his admission. He complained
of much pain during the operation, with frequent jerking of the
limb : the muscles were extremely rigid : five ligatures were
applied, and the wound dressed as usual.
The other foot presented the following appearance : The
protuberance of the os calcis had nearly disappeared ; but this
bone projected laterally, and on the outer side much beyond the
outer malleolus ; just under which, however, was a remarkable
depression. Immediately below the inner malleolus was a
X X2
340 DISLOCATIONS OF THE TARSAL BONES.
remarkable and unnatural projection. The whole foot seemed
somewhat displaced outwards, the toes turning out. The
astragalus must here have been dislocated from both the navi-
cular bone and os calcis, and thrown inwards, so as to have its
inferior articulatory surfaces for the os calcis resting on the inner
edge of that bone.
After the amputation, the dislocation was reduced by fixing the
knee, having the thigh bent at right angles with the body ; then
laying hold of the metatarsus and protuberance of the os calcis,
and drawing the foot gently and directly from the leg. During
this extension, Mr. H. Cline put his knee against the outside of the
joint, and the foot being pressed against it, the os calcis and navi-
cular bones slipped into the place, carrying with them the rest of
the foot, and the deformity disappeared. He was then carried to
bed, and an outside splint was applied, being well padded, and
secured by tapes ; and the leg, as far as could be, placed on the
outer side. Goulard's wash was applied.
June 24. The lead wash was left oif, and soap cerate put on
the right leg.
June 25. The cerate has blistered his leg in several places,
and he complains of more pain than yesterday at his ancle.
June 28. The stump, which is going on well, dressed to-day ;
one ligature came away. The pain in his ancle has subsided.
July 1. Complains of uneasiness about the epigastrium, and
sickness; pulse 112 and hard; svviij. blood taken from the ari^i.
July 2. All untoward symptoms have disappeared.
July 4. Two ligatures came away. A sore, which is the effect
of the soap cerate, on the inner malleolus, is dressed with wax
DISLOCATIONS OF THE TARSAL BONES. 341
and oil. He is now capable of raising- his leg-, which, however, is
benumbed.
July 13. The ligatures not appearing disposed to come away,
a piece of whale-bone was fixed on the side of the stump, to which
they were attached, and so kept constantly tight. Was put on
the hospital diet to-day ; had previously been on milk diet.
July 19. One of the ligatures was removed with some difficulty
by Mr. H. Cline ; the other came away easily on the following
day.
August 7. The man walked in the square for the first time
since the accident.
August 26. He went out, and was capable of walking tolerably
well.
I conversed with Mr. Henry Cline on the subject of these
accidents ; and Mr. Green, who saw the preceding case in the
commencement, sent me the following letter respecting it :
Lincolns Inn Fields, August 19, 1819.
My dear Sir,
In the notes of Martin Bentley's case, which I made at the
time when he was under Mr. Henry Cline's care in St. Thomas's
Hospital, I find it stated that the right astragalus was dislocated
inwards ; that is, that the os calcis, with the rest of the foot, was
thrown outwards : and the description which I have there given
of the appearance is, that the whole foot seemed to be somewhat
displaced outwards ; that the os calcis projected laterally much
beyond the outer malleolus, whilst the protuberance of that bone
342 DISLOCATIONS OF THE TARSAL BONES.
had nearly disappeared; and that, in consequence of the astragalus
retaining' its situation, there was a remarkable depression beneath
the outer malleolus, between it and the displaced os calcis ; and as
remarkable a projection, produced by the astragalus, helow the
inner malleolus. This accident, which was accompanied with a
compound fracture of the opposite leg, had been produced by the
fall of several large stones. The reduction of the dislocation was
effected without difficulty. First, by fixing the knee ; then by
making extension of the foot, gently and directly from the leg, by
laying hold of the heel with one hand, and placing the other on
the dorsum of the foot : and, lastly, by pressing the foot inwards,
whilst a counter pressure was made with the knee upon the lower
extremity of the tibia on the opposite side. The foot was after-
wards placed on its outside, and secured upon a well padded
splint.
In the case of compound luxation of the tarsal bones, likewise
under the care of Mr. Henry Cline, it appears, according to my
notes, that the astragalus was displaced outwards ; that is, that
the other tarsal bones were thrown inwards. I find that the
appearances are described to have been, that the foot was turned
considerably inwards ; that the articular surface on the head of
the astragalus, which is received into the cup of the navicular
bone, was exposed through an extensive, but tolerably clean, cut
through the integuments ; and that the articulating surface of the
OS calcis, with the astragalus, might also be perceived on the outer
side. The accident was said to have been occasioned by the fall
of a heavy stone, which had struck his heel. Reduction of the
dislocated parts was accomplished, first, by bending the leg so as
DISLOCATIONS OF THE TARSAL BONES. 343
to relax the muscles, and then by extending the foot in the
manner described in the former case, rotating" it at the same time
outwards.
The patient was a robust, but not corpulent, labouring man?
between forty and fifty years of age. He stated that he had been
in the habit of drinking, and that he was occasionally subject to
gout.
You have already, I believe, been made acquainted with the
particulars of the progress of the case, of which the most remark-
able features appeared to be, that the primary constitutional
irritation was violent, but of short duration ; and that his recovery
was retarded by extensive erysipelatous inflammation, which
terminated in sloughing, and by the formation of matter at the
part, accompanied by irritative fever and loss of strength ; but
that his recovery, although tedious, was complete.
Joseph Henry Green.
For the following case I am also indebted to Mr. Green, whom
I am proud to call my colleague, and who is an admirable
anatomist, an excellent surgeon, and an amiable man.
CASE V.
Thomas Toms, twenty-three years of age, was admitted into
St. Thomas's Hospital on July the 14th, 1820. He had fallen,
whilst engaged in his business, that of a bricklayer, from a three
story scaffold ; and his descent had been arrested by his foot
catching between the spikes of an iron railing, from which he
hung with his head nearly touching the ground. A wound was
34:4: DISLOCATIONS OF THE TARSAL BONES.
found extending beneath the inner malleolus of the left leg ; and
the head of the astragalus, which was torn from the articulatory
surface of the os naviculare, protruded through the divided
integuments. Part of the articulatory cartilage of the displaced
bone had been separated, and the bone was girt by the edges of
the wounded skin, which was puckered under it. The tendons of
the tibialis anticus and of the flexor muscles were tightly stretched,
and the foot was turned rather upwards and outwards. Further
examination shewed that the posterior tibial artery was torn
through, and that the accompanying nerve was partially lacerated.
An attempt was made to reduce the luxated astragalus by
fixing the knee, after having bent the leg upon the thigh, and by
making extension of the foot directly from the leg, laying hold of
the heel with one hand, and placing the other on the dorsum of
the foot. This, however, failed ; and as it appeared that the skin,
which firmly embraced the bone beneath, prevented the replace-
ment, it was divided, and the extension renewed, but with the
same unsuccessful result. This difficulty seemed to arise from the
small size of the wound in the capsule of the joint, and in
consequence of the bone being tightly held by the tendons.
Fearing, then, that the reduction was impracticable, I was led
to consider whether the amputation of the leg ought not to be
proposed. But Sir Astley Cooper happening to be in the hospital,
I requested him to see the case, and after a careful examination of
the injured limb he suggested that the astragalus might be
removed. I concurred, of course, in this proposal, as it afforded a
probability of saving the limb, and I proceeded accordingly to
perform the operation, I first applied a ligature on the posterior
DISLOCATIONS OF THE TARSAL BONES. 345
tibial artery, which, however, had not bled, the orifice being so
contracted that a pin could not have been introduced. I then
cautiously used a scalpel, detached the ligaments by which the
astragalus is connected with the bones of the leg and tarsus, and
found no considerable difficulty in removing the bone. The parts
were then readily brought into apposition, and the wound was
closed with straps of adhesive plaster. The leg was placed on its
outside, resting on a well padded splint, with a foot-piece ; the
foot was supported above the level of the knee, and the constant
use of an evaporating lotion was ordered.
In the evening of the same day slight fever had come on, but
the limb was tolerably easy ; and the patient had an evacuation
of the bowels.
The next day the febrile symptoms had increased. His pulse
was fuller and quicker, the skin was hot and dry, the tongue
furred, and thirst considerable ; but he had slept two or three
hours during the night, and the injured part was free from pain.
I ordered some febrifuge medicine, and directed that his diet
should be low, and that the apartment should be kept well
ventilated.
On the third day the fever was slightly increased. He com-
plained of pain at the ancle, which exhibited niarks of inflam-
mation, and he had had no stool. Sulphate of magnesia in the
infusion of roses was ordered in repeated doses, until the bowels
should be affected.
At my visit on the fourth day, I learnt that after having taken
five doses of the purgative medicine, two copious evacuations had
Y Y
346 DISLOCATIONS OF THE TARSAL BONES.
been produced. The fever still continued, but his tongue was
cleaner and moister. It was now found necessary to loosen the
splint-tapes, as the leg had become considerably swollen. Some
discharge of pus had taken place from the wound, and the pain
complained of the day before had subsided.
On the fifth day I found that he had passed a good night, and
the fever was less ; but he complained of a sore throat, and had
had a slight shivering.
On the sixth day I learnt that he had passed a sleepless night
in consequence of pain in the foot and leg, and that his head had
been somewhat affected. The pain in the limb had, however,
subsided ; and there was a copious discharge from the wound.
On the eighth day the fever seemed to be abated ; the pulse
was tranquil, and was not more than 86, and his bowels were
open. The dressings were now removed, and the ligature on the
artery came away. The wound had a healthy granulating
appearance. He was allowed to take some animal food.
He continued mending till July the 26th. His sleep had been
sound and refreshing ; he was free from fever, and from pain at
the injured part, and his appetite was improved. But on this day
it was found necessary to alter the position of the leg, by lowering
the foot, in order to favour the escape of matter which collected
in a sinus, extending about a third of the leg upwards, behind the
inner malleolus.
On July the 29th he began to complain of pain in the leg, and
he had some symptoms of constitutional disturbance. These
unpleasant effects were produced by the formation of an abscess,
DISLOCATIONS OF THE TARSAL BONES. 347
whieh was opened on the 1st of August, and from which about six
ounces of pus was discharged. He became after this tranquil and
easy, and the discharge of matter gradually decreased.
On August the 10th I ventured to have him removed into
another bed, but without disturbing the splints or pillows. The
wound at the ancle was now filled with granulations, and had in
part cicatrized.
On August the 25th his health had become again deranged.
His skin was hot, his countenance flushed, and he complained of a
good deal of pain at the outer ancle, where it rested on the splint.
In order to prevent this inconvenience the leg was placed in a
fracture box upon the heel, and a poultice was applied to the
ancle. On the following day it was evident that matter had
formed at the part, and an opening was therefore made, by which
about four ounces of pus were discharged.
During the ensuing week a discharge again took place from
the original wound. This flow of matter was copious, a consider-
able quantity being furnished from a sinus, extending to the calf
of the leg, and it continued till September the 7th. During this
period his leg became oedematous, his appetite declined, and he
was subject to slight hectic fever.
Subsequently to that date he rapidly improved : the oedema of
the leg subsided, the discharge lessened, and the wound assumed
a healthy appearance. He continued to mend till September the
22nd, when we were again troubled with the formation of one
small abscess on the inside of the leg, and of another just below
the calf of the leg. These were opened, and the discharge of
matter gradually subsided.
Y Y 2
348 DISLOCATIONS OF THE TARSAL BONES.
In the beginning of October the quantity of purulent discharge
was trifling'. He was now allowed to sit up, and straps of soap
cerate only were applied, with a roller.
On October the 25th the discharge had entirely ceased. The
parts about the joint were quite sound, and pressure produced no
inconvenience. He was capable at this time of performing to a
considerable degree the flexion of the foot on the leg, but could
not extend it.
He began now to walk a little with the aid of crutches ; and
continuing to gain health and strength, he was discharged from
the hospital on November the 2nd.
He has since resumed his business, and performs its duties
without inconvenience. J. H. Green.
DISLOCATION OF THE OS CALCIS AND
ASTRAGALUS.
The five anterior bones of the tarsus are sometimes dislocated
from the os calcis and astragalus. There is a joint placed
transversely between the os calcis and astragalus, and the os
naviculare and os cuboides ; and this joint is sometimes, but
rarely, luxated by very heavy weights falling upon the foot, of
which the following is an example :
Simple Dislocation.
CASE.
A man working at the Southwark Bridge had the misfortune to
i
DISLOCATIONS OF THE TARSAL BONES. 349
have a stone of great weight glide gradually on his foot : he was
almost immediately brought to Guy's Hospital, and the following
were the appearances of the foot. The os calcis and the astra-
galus remained in their natural situations, but the fore part of
the foot was turned inwards upon the bones. When examined
by the students the appearance was so precisely like that of a
club footf that they could not at jfirst believe that it was not a
natural defect of that kind : but upon the assurance of the man
that previously to the accident his foot was not distorted, an
extension was made by fixing the leg and the heel; the fore
part of the foot was then drawn outwards, and thus the reduc-
tion was effected. This person was discharged from the hospital
in five weeks, having the complete use of his foot.
The following interesting case was under the care of Mr.
Henry Cline; and for the particulars I am indebted to his
apprentice, Mr. South.
Compound Dislocation.
CASE.
Thomas Gilmore, an Irish labourer, aged forty-five years, was
admitted, under Mr. H. Cline, into St. Thomas's Hospital, about
eleven o'clock of the morning of March 28th, 1815. Whilst
walking at the New Custom House this morning, he received a
blow on the heel from the falling of a stone (said to be half a ton
weight), which made a wound on the fore part of the ancle-joint,
and dislocated the astragalus.
350 DISLOCATIONS OF THE TARSAL BONES.
The parts were in the following state: A wound extended
from opposite the middle of the base of the tibia, round the upper
part of the instep, to the external malleolus, which exposed the
articulating surface of the astragalus with the navicular bone on
the fore part, as well as that with the os calcis on the outside ;
from both of which bones the astragalus was displaced : its
connection with the tibia and fibula, however, was undisturbed.
The tuberosity of the os calcis projected outwards, but the rest
of the foot turned in, so that the toes pointed much inwards,
towards the opposite foot.
The reduction was effected by extending the foot, and rotating
it outwards ; the wound was brought together with straps of
adhesive plaster ; the leg was covered with soap plaster and put in
a fracture box, on the heel ; the parts were kept uncovered, and a
slight haemorrhage supervening, linen rags, dipped in cold water,
were applied.
He was a robust man, had been in the habit of drinking, and
says he has been subject to the gout.
March 29. Had not slept much, as on falling asleep spasm
was produced ; pulse about 80 ; skin cool ; he has taken the
sulphate of magnesia, which has produced two evacuations. The
part is not tumefied, but has been painful.
March 30. Has passed a very restless night, having been
delirious. Pulse 120; skin hot and dry; fauces parched. Does
not now seem quite clear in intellect. This morning he has had
more than one rigour. A dose of sulphate of magnesia, with
infusion of senna, had procured three loose, but healthy stools.
DfSLOCATIONS OF THE TARSAL BONES. 351
The part has become more swollen and painful. Ordered fever
mixture, with ten drops of antimonial wine, every six hours. In
the afternoon he had three more stools.
March 31. Is still delirious, and did not sleep last night. Skin
very hot and dry; mouth parched; pulse about 112. Has had
two stools this morning, without medicine. The rigours still
continue occasionally, and he is also affected with tremors. The
inflammation is extending- up the leg, and a bruise which he
received on the same leg is now ulcerating, to which a dressing
of wax and oil is applied.
April 1. Has been less delirious than on the two former
nights. Pulse 122; tongue cleaner ; no stools.
April 2. Has slept better than on the previous nights. Is not
at all delirious. Pulse 96 and soft ; skin moist, and he has
perspired freely ; no stools ; urine in large quantity, but said to
be high-coloured. The tremors have in a great measure left him,
and he feels altogether comfortable, except that there is a con-
siderable degree of pain in the injured part, which he ascribes
to a rheumatic affection to which he has been subject. There is
a slight erysipelatous inflammation of the leg, with some oedema.
April 3. Has passed a tolerably good night ; is sensible ; pulse
100 ; bowels costive ; the ancle easy.
April 4. Pulse 96 ; skin moist ; has had two stools. The
erysipelatous inflammation has extended rather above the internal
condyle of the os femoris, and small yellow vesicles have formed ;
this seems to have proceeded from the bruise on the calf of the leg,
which has now gone into a state of superficial ulceration. Soap
cerate was applied to this wound, and the spirit lotion on the limb,
»352 DISLOCATIONS OF THE TARSAL BONES.
as far as the inflammation extended. The wound on the ancle was
dressed for the first time to-day; the ligaments appear to he
sloughing ; the strapping was left off", and wax and oil dressing
was applied.
In the afternoon his pulse was 104 ; seems restless, and says
his head feels rather light : had another stool towards evening.
April 5. Has been delirious all night; skin hot and dry; pulse
108, and weak ; these symptoms indicate a fever of a diff'erent
kind to the preceding, viz. : secondary, and sympathetic, with the
erysipelas : the wound at the ancle is granulating, and secreting
healthy pus ; that on the leg is very painful, and has assumed a
sloughy appearance : ordered decoction of bark every four hours,
with opium, if diarrhoea is produced.
April 6. Is delirious ; pulse 1 00 and weak ; skin perspirable ;
has had two stools ; the inflammation extends nearly to the groin ;
and at one part of the thigh, where the cradle has accidentally
pressed the skin, it seems as if it would slough ; takes a grain of
opium twice a day.
April 7. Slept pretty well ; wanders; pulse 110, but strong;
skin not very hot ; no stool ; much pus is discharged from the
wound at the ancle.
April 8. Has been restless during the night ; pulse 96, with
some power ; skin moderately hot ; is thirsty ; delirious ; tongue
rather foul ; bowels costive ; his urine, of which he still voids a
great quantity, scalds him ; pus is forming in different parts of
the limb ; and the inflammation on the thigh seems now to be
stationary.
April 10. Slept well ; is not delirious ; pulse 96, not weak ;
DISLOCATIONS OF THE TARSAL BONES. 353
skin not very hot ; has appetite ; the part is painful, but the
inflammation on the thigh is considerably diminished, and the
sloug-hs are circumscribed ; pus healthy. A few days since he
was ordered a pint of porter daily, which is now increased to two
pints.
April ]]. Says he occasionally wanders; pulse 100, rather
weak ; appetite tolerably good ; skin moist ; has had stools.
April 12. The inflammation is less ; the opium which he takes
procures him good nights ; the wound at the ancle is much the
same ; the sloughing sore on the calf of the leg better ; to-day he
was moved into a clean bed, and the limb was placed on the outer
side, as he wishes to lie on his side.
April 13. Is composed ; pulse 98 ; skin cool ; feels weak; has
not much appetite, but likes his porter ; the sloughs on the leg-
separate slowly.
April 14. The limb was returned to its old position on the
heel, as he was less comfortable when it was placed on the side.
April 17. Pulse 92, and weak ; has little or no appetite ; the
bark and opium were left off* to-day, as they seem to affect his
head ; a poultice was applied to the wound on the calf of the leg,
and strapping on that at the ancle ; it being hoped, that by the
support thus afforded, the discharge would be diminished.
April 22. As his appetite does not improve, and he gets no
sleep, the bark and opium were resumed, and an additional pint of
porter given, so that he now takes three pints a day. His pulse is
not so weak; spirits good; at times he is in great pain; strapping
is applied to all the wounds ; the sloughs have not separated.
April 28. Continues much the same. One slough on the leg
z z
354 DISLOCATIONS OF THE TARSAL BONES.
has separated, that at the ancle not yet ; the part is tolerably
easy ; the discharge not great.
May 15. All the sloughs have separated, and the wounds are
gradually healing up, hut he is very weak, and his appetite is bad.
May iO. Oil was ordered to be rubbed on such parts of the leg
as would bear it, and then washed off, as it was thought this
would promote circulation in the limb, which was oedematous ;
however, this was soon discontinued, as it occasioned inflammation.
About this time his medicines were omitted.
May 29. An abscess, which had formed on the calf of the leg,
was opened.
July 14. All the dressings were left off to-day : he is perfectly
capable of lifting his leg, and has slight flexion and extension of
the foot.
After this time he rapidly improved : and having left his bed, in
a short time was walking about the square on crutches.
September 12. He went out, being able to walk tolerably
well with a stick.
DISLOCATION OF THE OS CUNEIFORMS INTERNUM.
I have twice seen this bone dislocated: once in a gentleman who
called upon me some weeks after the accident, and a second time
in a case which occurred in Guy's Hospital very lately. In both
these instances the same appearances presented themselves. There
was a great projection of the bone inwards, and some degree of
elevation, from its being drawn up by the action of the tibialis
DISLOCATIONS OF THE TARSAL BONES. 355
anticus muscle ; and it no longer remained in a direct line with
the metatarsal bone of the great toe. In neither case was the
bone reduced. The subject of the first of these accidents walked
with but little halting, and I believe would in time recover the use
of the foot, so as not to appear lame. The cause of the accident
was a fall from a considerable height, by which the ligament was
ruptured which connects this bone with the os cuneiforme medium,
and with the os naviculare.
The second case, which was in Guy's Hospital, my apprentice,
Mr. Babington, inforuis me, happened by the fall of a horse, and
the foot was caught between the horse and the curb-stone.
The treatment of this injury will consist in confining the bone
in its place, by at first binding it with a roller dipped in spirits of
wine and water, with which it must be constantly kept wet : and
when the inflammation is subdued, a leathern strap is to be buckled
around the foot, to keep the bone in its place till the ligament be
united.
The metatarsal bones I have never known luxated : their union
with each other, and their irreg-ular connection with the tarsus,
prevent itj and if it ever happens, it must be a very rare
occurrence.
DISLOCATION OF THE TOES FROM THE
METATARSAL BONES.
This is a very uncommon accident : but I had a man under my
care at Guy's Hospital, who had such a degree of lameness as to
Z Z 2
356 DISLOCATIONS OF THE TARSAL BONES.
be unable to get his bread by his daily labour, owing to an injury
sustained by falling from a considerable height, and alighting
upon the extremities of his toes. Upon examination of the bottom
of the foot, a considerable projection was found at the roots of all
the smaller toes, each of the extremities of the metatarsal bones
being placed under the first phalanges of the lesser toes. Several
months had elapsed from the time of the accident : and at first,
from the swelling of the foot, it had not been detected. No exten-
sion at the time when I saw him could answer any purpose, and
the only mode of relief was to wear a piece of hollow cork at
the bottom of the inner part of the shoe, to prevent the pressure
of the metatarsal bones upon the nerves and blood vessels.
The toes are sometimes dislocated, but as the mode of their
reduction will be the same as that of the fingers, I shall reserve
the subject until the dislocations of the fingers are described.
DISLOCATIONS OF THE LOWER JAW.
An articular cavity is formed behind the root of the zygomatic structure of
the articula-
process of the temporal bone, which receives the condyloid process ^^^^
of the lower jaw at the time when the mouth is shut ; and a
prominence which is placed before this cavity receives the lower
jaw when the teeth are advanced upon the upper : both the cavity
and the prominence are covered by articular cartilage. The
condyloid process of the jaw rests in the cavity with an inter-
vening cartilage whilst the mouth is shut, but it advances upon
the root of the zygomatic process when the jaw is much opened,
or the lower teeth are advanced. Between the condyloid process
and the cartilaginous surfaces, an interarticular cartilage is placed, interanicu-
having a double concave surface, which allows of the free motion
of the jaw, and of its advance upon the zygomatic articular
tubercle ; whilst the coronoid or anterior process of the jaw is
received between the zygomatic arch and the surface of the
temporal bone.
A capsular ligament unites the condyloid process to the temporal Ligaments.
358
DISLOCATIONS OF THE LOWER JAW.
Muscles.
Luxations.
cavity and to the prominence before it, and joins, in its passage
from one bone to the other, the
edge of the interarticular
cartilage ; whilst a strong internal lateral ligament passes from
the margin of the artictdar cavity to the inner surface of the angle
of the lower jaw.
The jaw is drawn upwards and downwards, backwards and
forwards, and transversely. Its elevation is produced by the
temporal, the masseter, and the pterygoideus internus : its depres-
sion by the platysma myoides, digastricus, mylo hyoideus, genio
hyoideus, and genio hyo glossus. The jaw is drawn backwards
by the temporal muscle, by a part of the masseter : and when the
OS hyoides is fixed by the digastricus, the genio hyoideus, and
genio hyo glossus, it is pulled forwards by a portion of the
masseter, and by the combined action of the pterygoidei externi.
The lateral motions of the jaw are principally produced by the
contractions of the external pterygoid muscles, which in alternate
actions pull the jaw from side to side, and give it, with the other
muscles, its grinding action, in which these muscles are assisted
by the oblique motion forwards, given to the jaw by the pterygoi-
deus internus.
The lower jaw is subject to two species of dislocation, viz. : the
complete and the partial When the dislocation is complete, both
the condyles of the jaw are advanced into the space between the
zygomatic arch and the surface of the temporal bone ; but when
it is partial, one condyloid process only advances, and the other
remains in the articular cavity of the temporal bone.
DISLOCATIONS OF THE LOWER JAW. 359
COMPLETE LUXATION OF THE JAW.
This is known to have happened by the open state of the mouth, J;°^t^J,„^
and by the impossibility of closing it, either by the patient's
efforts, or by pressure made upon the chin. The lower jaw may symptoms.
be still in some deg-ree approximated to the upper by muscular
efforts, but the lower teeth, if the mouth could be closed, would be
in a line anterior to the upper. Some degree of depression of the
jaw may also still be produced, but to an inconsiderable extent.
Thus the appearance of the patient is that of a continued
yawning'. The cheeks are projected by the advance of the
coronoid processes towards the buccinator muscle, and there is a
depression just anterior to the meatus auditorius, from the
absence of the condyloid process from its cavity. The saliva is
not retained in the mouth, but dribbles over the chin ; and a very
considerable increase of this secretion follows, in consequence of
the irritation of the parotid glands. The pain accompanying the
accident is severe, but I have never seen any dangerous effect
produced by it : on the contrary, the jaw becomes more nearly
closed by time, and a considerable degree of motion of the jaw is
recovered.
This accident may be caused by taking into the mouth too causes.
large a body, as I have known when two boys in play, struggling
for an apple, one has forced it into his mouth, and dislocated his
jaw. A blow upon the chin, when the mouth is widely opened,
produces the same effect. Yawning very deeply is also a fre-
quent cause of the accident.
360 DISLOCATIONS OF THE LOWER JAW.
A sudden spasmodic action of the muscles will produce this
dislocation when the mouth is opened, and it has often happened
in attempts to extract the teeth, where the mouth has been opened
too widely. Mr. Fox, the dentist, whose death we have to deplore
as a man of science, excellently well informed in his profession,
and a most amiable man in private life, told me that he was called
to a lady who had a tooth which required to be extracted, and
that in the attempt to do so, a sudden spasm dislocated the jaw.
Reduction.
The jaw must be immediately restored to its situation, and the
mode of reduction I shall explain by the following case.
CASE.
A madman, confined in one of the houses in Hoxton, during an
attempt to give him some food, which the keeper was obliged to
force him to receive, had his jaw dislocated. Mr. Weston,
surgeon in Shoreditch, was sent for, who, finding the man very
powerful and very unmanageable, preferred rather to send for
some other surgeon, to consider with him the best mode of making
the attempt at reduction. When I saw the man I thought that a
surgeon must be as insane as the patient who would employ the
usual means of reduction, and I therefore desired that the keepers
would place the patient on a table upon his back, with a pillow
under his head, and that he should be held by several persons. I
ordered two table forks to be brought me, and wrapped a hand-
kerchief around their points : placing myself behind the patient's
head, I carried the handles of the forks into the mouth, on each
Reduction.
DISLOCATIONS OF THE LOWER JAW. 361
side, behind the molares teeth ; then directed them to be held,
and placing my hand under the chin, I forcibly drew it to the
upper jaw, and the bone was easily and quickly reduced.
In the above-mentioned case the handles of the forks were not
used as levers, by lifting' them ; they only rested upon the jaw,
which was used as a lever upon them, depressing- the processes
as the jaw was elevated, and thus directing- the bone backwards
into its natural situation. But as wood is liable to injure the
g'ums, it is better to substitute two corks, which are to be placed coiks,
behind the molares teeth on each side of the mouth, and over
these the chin is to be raised. They are equally effectual in
reducing" the bone, and are less likely to injure it, or to bruise
the soft parts. It has been recommended in these cases, to
use a piece of wood as a lever, by introducing- it between the Levers.
molares teeth, first on one side and then on the other, reducing-
one side first, and then using the same means to the other. Mr.
Fox, in the case before alluded to, thus succeeded : he placed a
piece of wood, a foot long, upon the molar tooth on one side,
and raising it at the part at which he held it, depressed the point
at the jaw on that side, and succeeded in reducing the jaw. He
then did the same on the other side, and thus replaced the bone.
But the corks, the recumbent posture, and the elevation of the
chin, constitute the mode which I prefer.
In reducing this dislocation, the surgeon generally wraps a
handkerchief round his thumbs, placing them at the roots of the
coronoid processes, and depressing the jaw, he forces it backwards
as well as downwards, when the bone suddenly slips into its
AAA
»362 DISLOCATIONS OF THE LOWER JAW.
place: but this mode does not so easily succeed as the others,
excepting" in recent dislocations. When the jaw has been once
Liable to dislocated, it is very liable to the same accident, and therefore a
broad tape, with a hole cut in it to receive the chin, divided into
four ends by splitting it on each side some way down, is to be tied
over the summit of the head and occiput, to confine the jaw until
the lacerated parts have healed, by which the tendency to sub-
sequent luxation is diminished.
recur,
PARTIAL DISLOCATION OF THE JAW.
Partial dis- In tliis casc, the condyloid process advances under the zygomatic
arch on one side only, producing an incapacity to close the
mouth ; but it is not so widely opened as in the complete dislo-
symptoms. catiou. It is casy to distinguish this accident, as the chin is
thrown to the side opposite to the luxation, and the incisores teeth
are not only advanced upon the upper jaw, but are no longer in a
line with the axis of the face. The cause of this accident is a
blow on the side of the face when the mouth is opened, and in
one case it occurred from vomiting in sea sickness. In this
example, the lady, Miss Belfour, daughter of the late Admiral
Belfour, of Portsmouth, reduced her jaw by an oyster-knife,
which she turned half round upon the side of the jaw between
the teeth, and so returned it to its place.
In this injury, the lever of wood reduces the bone most easily,
DISLOCATIONS OF THE LOWER JAW. 363
but the cork may be used on one side, and the chin be elevated,
as in those cases in which the dislocation is complete.
SUBLUXATION OF THE JAW.
As in the knee, the thigh-bone is sometimes thrown from its symptoms.
semilunar cartilages, so the jaw appears occasionally to quit the
interarticular cartilage of the temporal cavity, slipping before its
edge, and locking the jaw, with the mouth slightly opened. It
generally happens, that this dislocation is quickly removed by
natural efforts alone ; but I have seen it continue for a length
of time, and the motion of the jaw, and the power of closing
the mouth have still returned. This state of the jaw happens Cause.
from extreme relaxation. The patient finds himself suddenly
incapable of entirely closing the mouth ; some pain is felt, and
the mouth is least closed on the side on which the pain is felt.
Force for removing these appearances must be applied directly Reduction.
downwards, so as to separate the jaw from the temporal bone,
and to give an opportunity for the cartilage to replace itself
upon the rounded extremity of the condyloid process.
In extreme degrees of relaxation, a snapping is felt in the Relaxation
^ ^ of ligaments.
maxillary articulation just before the ear, with some pain,
arising from the sudden relapse of the jaw into its socket,
which the relaxation of the ligament had permitted it to quit,
and to advance upon the zygomatic tubercle.
Young women are generally subject to this sensation, and
A A A 2
3^4 DISLOCATIONS OF THE LOWER JAW.
the means which I have found most frequently and quickly
tending to insure their recovery have been ammonia and steel
as medicine ; with the shower-bath, and the application of a
blister before the ear, when the complaint has continued for a
length of time.
DISLOCATIONS OF THE CLAVICLE.
As the clavicle is the only medium by which the arm is articu-
lated with the bones of the chest, it might be expected that its
dislocation would be extremely frequent ; but this bone is so
peculiarly and strongly articulated, both with the sternum and Dislocations
scapula, as to render its dislocation comparatively rare.
In other articulations we find a capsular ligament proceeding Articulation.
from the edges of the articulating surfaces and peculiar ligaments,
to give strength to the junction of the bones; but in the articula-
tion of the clavicle, like that of the lower jaw and knee, we meet
with an interarticular cartilage, composing a part of the articu-
lating apparatus.
JUNCTION OF THE STERNAL EXTREMITY OF THE
CLAVICLE WITH THE STERNUM.
The articulating surfaces, both of the sternum and clavicle, are Bo„es_
in part rounded, and in part depressed ; and both are covered by
366 DISLOCATIONS OF THE CLAVICLE.
Cartilage, ail ai'ticular cartilage similar to that of the other joints. A
capsular lig-artient proceeds from the end of the clavicle to the
edge of the articulating surfaces of the sternum, and it is
strengthened by short ligaments, which pass directly from one
bone to the other.
Within the capsular ligament is situated the interarticular
cartilage, joined at the upper part of the joint to the clavicle, and
to the capsular ligament ; and, below, to the edge of the articular
surface of the sternum, and to the capsular ligament ; it is inclined
under the end of the clavicle with the capsular ligament, so that
the clavicle rests upon its surface, and it is also interposed between
that bone and the sternum. Of that portion of this cartilage
which is inclined to the clavicle, only about one half is smooth,
to allow of the motion of that bone, and this is its lower and ante-
rior part. The residue of it adheres to the articular cartilag-e
of the clavicle, forming- a flat, rough surface ; but on the side
towards the sternum the interarticular cartilage forms a smooth
and concave surface, which allows of its free motion on that
bone. The interarticular cartilage is placed not perpendicularly,
but obliquely ; its upper end is inclined inwards, and its lower end
outwards, towards the first rib. From the upper point of the
brntmin"! claviclc proceeds an interclavicular ligament, which adheres to
the capsular ligament, and slightly to the sternum ; and traversing
the upper and back part of the sternum, it is fixed in Ihe extremity
of the opposite clavicle, and unites very strongly one clavicle to
the other.
Clavicular Thc claviclc is also ioined to the first rib by a clavicular costal,
costalliga- ^ ^ '^ •' '
»"«"♦• or, as it is called, rhomboid ligament, which proceeds from the
I
DISLOCATIONS OF THE CLAVICLE. 367
inferior edge of the sternal end of the clavicle to the cartilage of
the first rib.
The motion of the clavicle, as well as that of the sternum. Motion of
forwards and backwards, is performed upon the smooth surface of
the interarticular cartilage, which is applied to the sternum ;
whilst the motion of the clavicle, upwards and downwards, is
produced upon the portion of the smooth surface of the inter-
articular cartilage, which is applied to the clavicle ; and another
advantage is derived from this mode of articulation, which is, that
it allows of the motion of the bone outwards and backwards to a
considerable extent, without occasioning any weakness in the
ligament : for in this view it may be considered that there are two
ligaments, one from the clavicle to the cartilage, and one from the
cartilage to the sternum, instead of one loose, long ligament from
bone to bone.
DISLOCATION OF THE STERNAL EXTREMITY OF
THE CLAVICLE.
These are of two kinds, viz. : the dislocation forwards, the
clavicle being then thrown upon the sternum ; or backwards, when
the end of the bone is placed behind the sternum.
Dislocation Forwards.
The circumstances by which this injury is known are, that upon
looking at the upper part of the sternum a rounded projection is
368 DISLOCATIONS OF THE CLAVICLE.
seen, and when the fingers are carried upon the surface of the
sternum upwards, this projection stops them. If the surgeon
places himself behind the patient, puts his knees between the
scapulae, grasps the shoulders and draws them back, the projection
on the sternum disappears ; but directly when the shoulders
advance, the projection upon the sternum is renewed. The
clavicle may be readily traced with the finger into the projection
on the sternum. If the shoulder be elevated the projection
descends, if it be drawn downwards the dislocated extremity of
the bone becomes elevated to the neck. The motions of the
dislocated clavicle are painful, and the patient moves the shoulder
with difficulty. The point of the injured shoulder is less distant
from the central line of the sternum than usual. In a verv thin
person the nature of the accident can be at once ascertained,
because the bone is but little covered ; but in fat persons it is
more difficult to detect. When the patient is at rest very little
pain or tenderness is felt from the accident. It sometimes
Partial. liappcus that this dislocation is incomplete, the anterior portion
of the capsular ligament only being torn, and the bone slightly
projected ; but generally all the ligaments are lacerated, and the
bone, with its interarticular cartilage, is thrown forwards.
Its cause. Thc causc of this injury is a fall upon the point of the shoulder,
when the force pushes the clavicle inwards and forwards, and
projects it on the sternum ; but it also frequently happens from
a fall upon the elbow, at the time it is separated from the side,
by which the clavicle is forced violently inwards and forwards
against the anterior part of the capsular ligament.
Reduction. With rcspcct to the means of reduction and the principle upon
DISLOCATIONS OF THE CLAVICLE. 369
which the treatment is to be regulated, there is no difficulty in
practising' the one, or in understanding the other. The clavicle
is easily returned to its place by pulling the shoulder backwards,
because then it is drawn off the sternum, and its end falls upon
the cavity which naturally received it ; but if pressure in this
position of the shoulder be not made upon the fore part of the
bone, it will be found still liable to project in some degree.
The principle, therefore, upon which the extension is made, is Principle.
to draw the scapula as far from the side as is practicable without
inconvenience, and by supporting the arm, to prevent its weight
from influencing the position of the bone.
The first of these objects is best effected by the use of the Mode of
" '' extension.
clavicle bandage (see plate), and by the application of two
pads or cushions affixed to it, which are placed in the axillee.
These pads throw the head of the os humeri from the side, and
carry the scapula, and the clavicle connected with it, outwards
and backwards, and thus the clavicle is drawn into its natural
articular cavity. The second intention is effected by putting the
arm in a sling, which, through the medium of the os humeri and
scapula, supports it, and prevents the clavicle from being drawn
down by the weight of the arm.
Dislocation Backwards.
The dislocation of the extremity of the bone backwards I have Dislocation
I f, ,•, . ' . • \ L 1 C backwards.
never known occur irom violence, yet it might happen irom
excessive force, as from a blow upon the fore part of the bone,
which should tear the capsular and clavicular costal ligament,
and allow the bone to glide behind the sternum, occasioning
B B B
370 DISLOCATIONS OF THE CLAVICLE.
compression of the oesophagus, and rendering deglutition difficult.
The trachea would, from its elasticity, elude pressure, and escape
to the opposite side of the space by which this tube enters the
thorax.
Cause. The. only cause of this dislocation that I have known, was
produced by great deformity of the spine, by which the scapula
advanced, and sufficient space was not left for the clavicle, between
the scapula and sternum ; in consequence of which, the bone
gradually glided back behind the sternum, and produced so much
inconvenience by its pressure on the oesophagus, as to lead to a
necessity for the removal of its sternal extremity.
This case is extremely creditable to the knowledge, skill, and
dexterity of Mr. Davie, surgeon at Bungay, in Suffolk ; few would
have thought of the mode of relief — very few would have dared to
perform the operation — and a still smaller number would have
had sufficient knowledge to accomplish it.
The following particulars I in part received in conversation with
Mr. Davie, who fell a victim to his great professional zeal, and in
part from Mr. Henchman Crowfoot, surgeon at Beccles, who, to
high professional skill, adds all the amiable qualities which can
become a man. He had the kindness to go over to Dr. Camell,
of Bungay, to learn from him some of the particulars, and there
met with a person who gave him several others, and who knew
the patient for some years after the operation.
CASE.
Case. Miss Loffly, of Metfield, Suffolk, had a great deformity, arising
from a distorted spine, increased by an accident which displaced
1
DISLOCATIONS OF THE CLAVICLK.
the sternal extremity of the left clavicle, and threw it behiod the
sternuiu. The progressive distortion of the spine gradually
advanced the scapula, and occasioned the sternal end of the
clavicle to project inwards, behind the sternum, so as to press
upon the oesophagus, and occasion extreme difficulty in deglu-
tition. Her deformity had become excessive, and her emaciation
extreme.
Mr. Davie conceived that he should be able to prevent the
gradual destruction which the altered position of the clavicle
threatened, by removing the sternal extremity of the bone ; and
the operation which he performed for this purpose was, according
to all I can learn, as follows :
An incision was made of from two to three inches in extent on
the sternal extremity of the clavicle, in a line with the axis of that
bone ; and its surrounding ligamentous connections, as far as he
could then reach them, were divided with the saw of Scultetus
(often called Hey's) ; he sawed through the end of the bone, one
inch from its articular surface from the sternum, and fearful of
doing unnecessary injury with the saw, he introduced a piece of
well beaten sole leather under the bone whilst he divided it.
When the sawing was completed he tried to detach the bone, but
it still remained connected by its interclavicular ligament, and he
was obliged to tear through that ligament by using the handle of
the knife as an elevator, and after some time succeeded in
removing the portion of bone which he had separated.
The wound healed without any untoward occurrence, and the
patient was enabled to swallow, as the pressure of the clavicle
upon the oesophagus was now removed.
B B B 2
372 DISLOCATIONS OF THE CLAVICLE.
She lived six years after the operation, and recovered consider-
ably from her former emaciation. " Of what she ultimately died,"
says Mr. Crowfoot, " I have not learnt."
JUNCTION OF THE CLAVICLE WITH THE SCAPULA.
Articulation. Xhc claviclc joins with the scapula about three quarters of an
inch behind the extremity of the acromion. The end of the
clavicle is slightly convex, and covered by an articular cartilage ;
the scapula is depressed to receive it, and this surface is also
covered by an articular cartilag-e. Strong ligamentous fibres pass
directly from the clavicle to the scapula, and under these a
capsular ligament is extended from the edge of the socket of the
scapula, to the extremity of the clavicle. The surface of junction
is very small, the end of the clavicle not being longer than the
end of the little finger of an adult ; and the cavity in the scapula
which receives it is very superficial, being not larger than is
required to receive upon its surface the end of the clavicle. But
the junction of the two bones is effected by much stronger means,
through the medium of the coracoid process of the scapula, which
Ligaments. SGuds foi'th two Hgameuts to the clavicle. The first proceeds from
the root of the coracoid process, and is fixed in a small tubercle of
the clavicle on its under side, at the insertion of the subclavius
muscle, and tuo inches from the extremity of the bone. This
Internal Hgameut has been called the conoid, from its form, but may be
coraco-cla-
viouiar. better named the internal coraco-clavicular. The use of this
1
DISLOCATIONS OF THE CLAVICLE. 373
ligament is, to bind down the clavicle to the scapula, and to
confine the motion of the clavicle forwards and upwards.
The second ligament of this part is called trapezoid; it proceeds
from the coracoid process, and passes on the under side of the
clavicle to near its scapular end, into which it is fixed ; I call it
the external coraco-clavicular. This ligament is the chief cause External
coraco-cla-
Avhich lessens the tendency to dislocation of the scapular end of '•<="'*'^-
the clavicle, for when its capsular ligament is divided, the scapula
cannot be forced under the clavicle without lacerating this
ligament, so great is its resistance. It allows of very free motion
of the scapula backwards and upwards, but confines its motions
forwards. The inotions of this extremity of the clavicle are
performed by the subclavius muscle, although other muscles
also move this bone.
DISLOCATION OF THE SCAPULAR EXTREMITY OF
THE CLAVICLE.
This accident is more frequent than the dislocation of the
sternal extremity.
When this extremity of the bone is luxated, the signs by which
the surgeon ascertains the nature of the injury are as follows ;
The shoulder on that side, when compared with the opposite, gy^pto^s
appears depressed, for the clavicle is formed to give support to
the scapula, and that support is lost in consequence of the
accident. The point of the shoulder approaches nearer to the
374 DISLOCATIONS OF THE CLAVICLE.
sternum ; and if the distance of the two shoulders from that bone
be measured, this inequality is directly detected ; the clavicle
being naturally the means of preserving- the distance of the
scapula from the side, to throw out the shoulders, and to render
- the motions of the arm extensive. But the easiest mode of
detecting this accident is, to place the finger upon the spine of
the scapula, and to trace this portion of bone forward to the
acromion in which it ends ; the finger is stopped by the pro-
jection of the clavicle, and so soon as the shoulders are drawn
back, the point of the clavicle sinks into its place, but it reap-
pears when the shoulders are let go. The point of the clavicle
projects against the skin upon the superior part of the shoulder,
and much pain is felt when it is pressed.
In this injury, the capsular ligament is necessarily torn through,
as well as the external ligament, from the coracoid process to the
clavicle, or no dislocation of the sternal extremity could occur.
The internal ligament, when the dislocation is complete, must be
also lacerated ; but I have seen the clavicle project but slightly
on the acromion in some of these accidents, denoting that the
latter ligament had not given way.
It is scarcely probable, that the clavicle should be ever dislo-
cated in any other direction than upwards. At least, I have never
seen an instance of the clavicle gliding under the acromion, but
I would not deny the possibility of such an accident.
This species of dislocation is caused by a fall upon the shoul-
ders, through which the scapula is forced inwards towards the
ribs, and the accident which produces it is excessively violent.
It has been said, that the action of the trapezius muscle alone
Cause.
DISLOCATIONS OF THE CLAVICLE. 375
could produce this effect, but that is impossible, as this muscle
would not influence both the ligaments of the coracoid process,
which must be torn throug'h to produce the dislocation.
In the treatment of this accident, I adopt the following plan : Reduction.
The assistant, standing behind the patient, puts his knee between
the shoulders, and draws them backwards and upwards, when the
clavicle sinks into its socket. A thick cushion is then placed in
each axilla, for three purposes : First, to keep the scapula from
the side ; Secondly, to raise the scapula : Thirdly, to defend
the axillae from being hurt by the bandages: on which last
account a cushion is employed on each side. Then the clavicle
bandage is applied, and its straps should be sufficiently broad to
press upon the clavicle, the scapula, and the upper part of the
OS humeri, to keep the former down, the scapula inwards and
backwards (which is the chief object), and the arm backwards
and elevated. To secure these objects more effectually, the arm Mode.
is to be suspended in a short sling, by which it is made to sup-
port the scapula in its proper situation.
At the conclusion of my lecture upon this subject I have always
given this counsel to the pupils: — "You are not to expect that the
parts, after the utmost care in the treatment, will, in dislocations
of either end of the clavicle, be very exactly adjusted ; some
projection, some slight deformity will remain ; and it is necessary,
from the first moment of the treatment, that this should be stated
to the patient, as he may otherwise suspect that the fault
has arisen from your ignorance or negligence. You may at
the same time inform him, that a very good use of the limb
will be recovered, although some deviation from the natural
376 DISLOCATIONS OF THE CLAVICLE.
form of the parts may remain, in a slight projection on the
sternum, or some elevation of the sternal extremity of the
clavicle."
DISLOCATION OF THE CLAVICLE WITH
FRACTURE OF THE ACROMION.
We have a preparation of this injury in the Museum at St.
Thomas's Hospital, and the following account of the case was
given me hy Mr. South.
Case. A man, aged sixty years, was admitted into King's Ward, St.
Thomas's Hospital, Oct. 19, 1814, having fallen from a tree two
or three days before. The surgeon to whom he applied told him
that nothing was injured ; but he himself persisted in saying his
shoulder was broken, and walked up from Maidstone to the
hospital. On examination, his shoulder appeared fallen as if
displaced, but a little attention shewed that this was not the
case. What, however, the accident was determined to be, I do
not recollect, but the following treatment was adopted. Cushions
were put in the axillae, and a stellate bandage applied, with
another just above the elbow to bind it to the side, and the arm
was put in a sling, which seemed to keep the parts in their proper
position ; but the next morning the bandages were loose. Sup-
posing that this effect was produced by restlessness, they were
again applied, but continued slipping off, day after day, until a
week from his admission, when a long splint, placed across the
shoulders, was bound to them by rollers, and the parts resumed
DISLOCATIONS OF THE CLAVICLE. 377
their natural situation ; but after a short time, they were also
obliged to be removed on account of the extreme irritability of
the patient. He was then ordered to lie in bed upon his back
without any bandage, but the parts became again displaced. No
other attempt at relief was made, and he died on December the
7th following, of some pulmonary disease, after an illness of three
weeks.
On examination of his body, the clavicle was found dislocated ciavicie ais-
at its scapular extremity, and projected considerably over the
spine of that bone. The acromion process, just where the clavicle Acromion
• I • 11 n' broken.
is united with it, was broken oiF.
The splint across the shoulders seemed likely to succeed in
keeping the parts in apposition, if the man's illness and impa-
tience would have permitted him to continue to wear it.
C C C
process.
STRUCTURE OF THE SHOULDER-
JOINT.
Shoulder- The shoulder-joint is composed of two portions of bone ; the
glenoid cavity of the scapula, and the head of the os humeri.
Glenoid The ^Icnoid cavity is similar in form to a longitudinal section
cavity. a J O
of an egg, with its larger extremity downwards and outwards,
and its smaller upwards and inwards ; the cavity is so superficial,
that the head of the humerus rather rests upon its surface than
is received into its hollow ; it is, however, slightly concave, and is
covered by an articular cartilage, which is somewhat extended
beyond the edge of the bony cavity.
coracoid The coracoid process of the scapula is situated at the upper
point of the glenoid cavity, and its basis extends from thence to
the notch of the superior costa ; it rises and inclines inwards and
forwards, terminating in a point, which is situated under the
clavicle, one third the length of that bone from its junction with
the spine of the scapula, and on the inner side of the head of the
OS humeri, under the pectoral muscle. It covers and protects the
joint on its inner side.
STRUCTURE OF THE SHOULDER-JOINT. 379
The glenoid cavity is united to the body of the scapula by cervix
a narrow neck, which is called the cervix scapulae ; and its
narrowest part is opposite to the notch of the superior costa of
the scapula.
The head of the humerus is divided into three portions. The Head of the
n • ' 1 f o • 11 ^1 1 ' 1 humerus.
nrst IS an articular surface tormmg a small part of a sphere, which
rests upon the glenoid cavity of the scapula, and is covered with
an articular cartilage ; the second is a process called the larger
tubercle, formed for the insertion of three muscles ; it is situated
on the outer portion of the head of the bone, under the deltoid
muscle; and the third is a process called the lesser tubercle,
which is situated on the inner side of the head of the bone towards
the axilla; and in the usual position of the arm, nearly in a line
with the point of the corocoid process of the scapula.
Between these two processes is a groove, which lodges the Bicepitai
1 • 11 groove,
tendon of the long-head of the biceps muscle, and is termed the
bicepitai groove.
Immediately below the head of the humerus is situated that
portion of the bone called the cervix humeri. humeri.
The capsular ligament of this joint surrounds the head of the capsular
bone, and is attached to the whole circumference or the edge ot
the glenoid cavity, excepting where the tendon of the biceps
muscle passes under it; and at that point it arises from a ligament
which proceeds from the coracoid process to the edge of the
glenoid cavity. The capsular ligament is also fixed to the two
tubercles, and towards the axilla, to the neck of the humerus, just
below its articular surface. This ligament is not of an uniform
thickness ; but at those parts where the joint is not defended from
C C C 2
380 STRUCTURE OF THE SHOULDER-JOINT.
injury by the tendinous insertions of muscles, the capsular
ligament itself is thickened, and is capable of sustaining great
violence ; and this difference is remarkably shewn in that part
of the ligament which is placed in the axilla, it being of a
strong tendinous nature.
Four muscles are destined to move the os humeri, and to
strengthen the capsular ligament. The first, the supra-spinatus,
vVhich arises from the fossa supra-spinata, covers the head of the
Muscles of bone, blends its tendon with the capsular lia^ament, and is inserted
protection ' i o
to the joint, -j^^^ ^^ larger tubercle; the second, the infra-spinatus muscle,
which proceeds from the fossa infra-spin ata, adheres to the back
part of the capsular ligament, and is also fixed to the greater
tubercle ; the third, the teres minor, which arises from the lower
edge of the scapula, adheres to the bax^k part of the capsular
ligament, and is inserted into the greater tubercle, and into the
cervix humeri ; the fourth is the subscapularis muscle, which fills
up the venter, or inner concave surface of the scapula : it passes
over the inner side of the head of the bone, and is fixed to the
smaller tubercle, firmly adhering to the capsular ligament as it
passes over its inferior and inner surface. It is between the
subscapularis muscle, and the teres minor, that the capsular
ligament is found of great strength, as there are no muscles
inserted into that part to protect the joint from injury.
Muscles of The deltoid muscle, the coraco-brachialis, and the teres majorj
thejoint. which are also muscles of this joint, are not united with the cap-
sular ligament as the other muscles, being only destined for the
motion, and not particularly for the protection of the shoulder-
joint.
STRUCTURE OF THE SHOULDER-JOINT. 381
The tendon of the long'-head of the biceps protects the upper Tendon of
part of the joint, where it otherwise would be weak ; for this
tendon is situated between that of the supra-spinatus and sub-
scapularis : it arises from the upper point of the edge of the
glenoid cavity of the scapula, and passes over the head of the
bone into the groove between the two tubercles and the portion
of the capsular ligament. Reflected towards the articular carti-
lage of the OS humeri it adheres to the surface of this tendon, so
that the synovia is prevented from escaping.
The shoulder-ioint has a g-reater extent and variety of motion cause of the
'' ^ ^ ^ _ *' frequent dis-
than any other joint in the body; and its dislocations are, conse- 5^^f^°?f
quently, more frequent than those of all the other joints in the
body collectively : those of the ancle-joint being next in frequency.
DISLOCATIONS OF THE OS HUMERI.
Four kinds
of disloca-
tion.
This bone is liable to be thrown from the glenoid cavity of the
scapula in four directions; three of these luxations are complete,
and one is partial only.
Downwards Thc fivst is downwards and inwards ; it is usually called the
and inwards.
dislocation into the axilla, and in this accident the bone rests
upon the inner side of the inferior costa of the scapula.
The second is forwards upon the pectoral muscle, when the
head of the os humeri is placed below the middle of the clavicle,
and on the sternal side of the coracoid process.
The thh'd is the dislocation backwards, when the head of the
bone can be both felt and distinctly seen, forming a protuberance
on the back and outer part of the inferior costa of the scapula,
and situated upon its dorsum.
Partial dis- Thc foiirtJi is Only partial, when the anterior portion of the
locations.
capsular ligament is torn through, and the head of the bone is
found resting against the coracoid process of the scapula, on its
outer side.
Forwards.
Backwards.
DISLOCATIONS OF THE OS HUMERI. 383
It has been supposed that a dislocation of the os humeri of the ais-
. location up-
upwards might occur, but it is obvious that this could only '^^''^*-
happen under fracture of the acromion. It is an accident which
I have never seen.
Of the dislocation in the axilla I have seen a multitude of dislocation
in the axilla.
instances ; of that forwards on the inner side of the coracoid
process several, although these are much less frequent than that
in the axilla ; of the dislocation backwards I have seen only two
instances during the practice of my profession for thirty-eight
years. I do not believe in any change of place after dislocation,
when the muscles have once contracted (except from subsequent
violence, which is very uncommon), beyond that slight change
which pressure, by producing absorption, will sometimes occasion.
The bone is generally at once thrown into the situation which it
afterwards occupies ; so that excepting from circumstances of
great violence, the nature and direction of the dislocation are not
subsequently changed.
?ns of dis-
DISLOCATION IN THE AXILLz^.
The usual signs of this dislocation are as follows : A hollow is sign
produced below the acromion, by the displacement of the head of theaxiiia.
the humerus from the glenoid cavity, and the natural roundness of
the shoulder is destroyed, because the deltoid muscle is flattened
and dragged down with the depressed head of the bone. The
arm is somewhat longer than the other, as the situation of the
bone upon the inferior costa of the scapula is below the level of
384 DISLOCATIONS OF THE OS HUMERI.
the glenoid cavity. The elbow is with difficulty made to touch
the patient's side, from the pain produced in this effort by pressure
of the head of the bone upon the nerves of the axilla ; and upon
this account it usually happens, that the patient himself supports
his arm at the wrist or fore arm with the other hand, to prevent
its weight pressing upon these nerves. The head of the os
humeri can be felt in the axilla, but only if the elbow be consi-
derably removed from the side. I have several times seen sur-
geons deceived in these accidents, by thrusting the fingers into
the axilla when the arm was close to the side, when they have
directly said, " this is not a dislocation ;" but upon raising the
elbow, the head of the bone could be distinctly felt in the axilla ;
for that movement throws the head of the bone downwards and
more into the axilla.
The motion of the shoulder is in a great degree lost, more
especially in the direction upwards and outwards, for the patient
can no longer raise his arm by muscular effort, and even the
surgeon generally finds some difficulty in overcoming its fixed
position; it is usual, therefore, as a first question in detecting
dislocation, to ask the patient if he can raise his arm to his head,
and if there be dislocation, the answer is invariably that he cannot.
The power of rotation of the arm is also lost ; but the motion of
the limb forwards and backwards, as it hangs by the side, is still
preserved. There is, however, great difference in respect to the
motion of the limb, and this depends upon the age of the patient ;
in old people, the relaxed state of the muscles will not only admit
of motion, but allow the surgeon to carry the arm to the upper
part of the head. On moving the limb, a slight crepitus will
DISLOCATIONS OF THE OS HUMERI. 385
sometimes be felt from Inflammatory effusion, and from the
escape of synovia, but by the continuance of the motion this
soon ceases ; the crepitus, however, in these cases, is never so
strong as that which a fracture produces. The central axis of
the arm is changed, for the central line runs into the axilla.
In this accident, numbness of the fingers frequently occurs,
from the pressure of the head of the bone upon a nerve, or the
nerves of the axillary plexus.
These are the circumstances of greatest moment ; but it will
be seen that the accident can be detected principally by the fall
of the shoulder, by the presence of the head of the bone in the
axilla, and by the loss of the natural motions of the joint. But circum-
a few hours make these appearances much less decisive, from the render the
nature of the
extravasation of blood, and from the excessive swellina- which 2'=",'^^"*'^'^'
o ficult to as-
sometimes ensue ; but when the effused blood has become *'^''*'"'
absorbed, and the inflammation has subsided, the marks of the
injury become again decisive. At this period it is that surgeons
of the metropolis are usually consulted ; and if we detect a dislo-
cation which has been overlooked, it is our duty, in candour, to
state to the patient, that the difficulty in the detection of the
nature of the accident is exceedingly diminished by the cessation
of inflammation, and the absence of tumefaction.
It may be also observed, that there is great difference in the circum-
„.,. ., Ill •! •!• !• 1* Stances that
facility with which the accident is discovered m thin persons, fender it
easy.
of advanced age, and in those who are loaded with fat, or who
have, by constant exertion, rendered their muscles excessively
large.
D D D
386 DISLOCATIONS OF THE OS HUMERI.
Dissection of the Dislocation into the Axilla.
I have dissected two cases of recent dislocation downwards.
A sailor fell from the yard-arm on the ship's deck, injured his
skull, and dislocated the arm into the axilla. He was brought
into St. Thomas's Hospital in a dying state, and expired immedi-
ately after he was put into his bed. On the following day I
obtained permission to examine his shoulder, which I removed
from the body for the purpose of obtaining a more minute exami-
nation, and the following were the appearances which I found :
On removing the integuments, a quantity of extra vasated blood
presented itself in the cellular membrane, lying immediately under
the skin, and in that which covers the axillary plexus of nerves,
as well as in the interstices of the muscles, extending as far as the
cervix of the humerus, below the insertion of the subscapularis
muscle.
Appear- T^c axillai'y artery, and plexus of nerves, were thrown out of
the dis"ec- their course by the dislocated head of the bone, which was pushed
limb. backwards upon the subscapularis muscle. The deltoid muscle
was sunken with the head of the bone. The supra and infra
spinatus were stretched over the glenoid cavity and inferior costa
of the scapula. The teres major and minor had undergone but
little change of position ; but the latter, near its insertion, was
surrounded by extravasated blood. The coraco-brachialis was
uninjured. In a space between the axillary plexus and coraco-
brachialis, the dislocated head of the bone, covered by its smooth
articular cartilage and by a thin layer of cellular membrane.
DISLOCATIONS OF THE OS HUMERI. 387
appeared. The capsular lig"ament was torn on the whole length
of the inner side of the glenoid cavity, which would have admit-
ted a much larger body than the head of the os humeri
through the opening. The tendon of the subscapularis muscle,
which covers the ligament, was also extensively torn. The open-
ing of the ligament, by which the tendon of the long-head of the
biceps passed, was rendered larger by laceration, but the tendon
itself was not torn. The head of the os humeri was thrown on
the inferior costa of the scapula, between it and the ribs; and the
axis of its new situation was about an inch and a half below that
of the glenoid cavity, from which it had been thrown.
The second case which I had an opportunity of examining was
one in which the dislocation had existed five weeks, and in which
very violent attempts had been made to reduce the dislocated
bone, but without success. The subject of the accident was a
woman fifty years of age. All the appearances were distinctly
marked ; the deltoid muscle being flattened, and the acromion
pointed ; the head of the bone could also be distinctly felt in •
the axilla ; the skin had been abraded during the attempts at
reduction, and the woman apparently died from the violence used
in the extension. Upon exposing the muscles, the pectoralis
major was found to have been slightly lacerated, and blood
effused ; the latissimus dorsi and teres major were not injured ;
the supra-spinatus was lacerated in several places ; the infra-
spinatus and teres minor were torn, but not to the same extent
as the former muscle. Some of the fibres of the deltoid muscle
and a few of those of the coraco brachialis had been torn ; but
D D D 2
388 DISLOCATIONS OF THE OS HUMERI.
none of the muscles had suffered so much injury as the supra-
spinatus. The biceps was not injured.
Having ascertained the injury which the muscles had sustained
in the extension, and, in some degree, the resistance which they
opposed to it, I proceeded to examine the joint.
The capsular ligament had given way in the axilla, between
the teres minor and subscapularis muscles ; the tendon of the
subscapularis was torn through at its insertion into the lesser
tubercle of the os humeri (see plates) ; the head of the bone
rested upon the axillary plexus of nerves and the artery. Having
determined these points by dissection, I next endeavoured to
reduce the bone, but finding the resistance too great to be over-
come by my own efforts, I became very anxious to ascertain its
origin. I therefore divided one muscle after another, cutting
through the coraco-brachialis, teres major and minor, and infra
spinatus muscles : yet still the opposition to my efforts remained,
and with but little apparent change. I then conceived that the
deltoid must be the chief cause of my failure, and by elevating
the arm, I relaxed this muscle ; but still could not reduce the
dislocation. I next divided the deltoid muscle, and then found
the supra-spinatus muscle my great opponent, until I drew the
arm directly upwards, when the head of the bone glided into the
glenoid cavity. The deltoid and supra-spinatus muscles, are
those which most powerfully resist reduction in this accident.
It appears from these dissections, that the best direction in
which the arm may be extended for reduction, is at a right angle
with the body, or directly horizontally, rather than obliquely
DISLOCATIONS OF THE OS HUMERI. 389
downwards ; as the deltoid, supra and infra spinati muscles, are,
in this position of the limb, thrown into a relaxed state, and these
muscles are, as I have explained, the principal sources of the
resistance. The biceps is to be relaxed by slightly bending the
elbow. The arm may be extended directly outwards, in the line
between the pectoralis major on the outer side, and the latissimus
dorsi and teres major on the inner ; but if there be any deviation
from this line, it will be better rather to advance the arm, to
lessen the power of the pectoralis major.
This dissection explains the reason why the arm is sometimes
easily reduced soon after the dislocation, by raising it suddenly
above the horizontal line, and placing the fingers under the head
of the bone, so as to raise it towards the glenoid cavity, which,
as every tyro knows, will sometimes prove effectual, because, in
this position, the muscles of opposition are relaxed so as to oppose
no resistance to reduction.
Dissection of a Dislocation which had been long
Unreduced.
The head of the bone is found altered in its form ; the surface Dissection
of an old
towards the scapula being flattened, a complete capsular ligament dislocation.
covers the head of the os humeri. The glenoid cavity is com-
pletely filled by ligamentous matter, infused by a slow inflam-
matory process ; in this ligamentous matter are suspended small
portions of bone, which appear to be of new formation, as no
portion of the scapula or humerus is broken ; a new cavity is
of its recur-
390 DISLOCATIONS OF THE OS HUMERI.
formed for the head of the os humeri on the inferior costa of the
scapula, but this is glenoid, like that from which the os humeri
had escaped. (See plate.)
Causes of ^^hc commoH causes of dislocation of the os humeri into the
into the axilla are, falls upon the hand while the arm is raised above an
horizontal line, by which the head of the bone is thrown down-
wards ; also, a fall upon the elbow, when the arm is raised from
the side ; but the most frequent cause is, a fall directly upon
the shoulder on some uneven surface, by which the head of the
bone is driven downwards, whilst the muscles are but ill pre-
pared to resist the shock.
Frequency Whcu thc ami has been once dislocated, if great care be not
taken of the limb after its reduction, it is extremely liable to a
recurrence of the accident, I remember, particularly, a carpenter,
who used to be a frequent visitor at Guy's Hospital for several
years, for the purpose of having his shoulder reduced. Slighter
causes than that which originally produced it, will renew the
dislocation ; I have known it to recur from the act of throwing up
the sash of a window. During my apprenticeship at St. Thomas's
Hospital, in going through the wards early one morning, I was
directed to see a man who had just dislocated the shoulder, which
he had frequently done before, as he was lying in bed ; and upon
inquiring how it had happened, the man replieds that it occurred
merely in the effort of rubbing his eyes and stretching himself,
upon waking ; but this disposition to the recurrence of dislocation
may be prevented, by directing that the arm be kept fixed close
to the side, and the shoulder rather elevated by a pad in the
axilla, for three weeks after its reduction ; during which time
DISLOCATIONS OF THE OS HUMERI. 391
the ruptured tendon of the subscapularls, and the capsular
ligament will be united : a process which motion greatly impedes,
if not wholly prevents.
Reduction of the Dislocation in the Axilla.
Various have been the means suggested for the reduction of Means em.
the head of the humerus, when dislocated downwards into the reduction"!
axilla; but under the different circumstances attending this
accident, different means must be employed ; the first, and that
which I usually adopt in my private practice in all recent cases, is
By the Heel in the Axilla :
And the best mode of its application is as follows : The patient
should be placed in the recumbent posture, upon a table or a sofa,
near to the edge of which he is to be brought ; the surgeon then
binds a wetted roller round the arm immediately above the elbow,
upon which he ties a handkerchief; then, with one foot resting
upon the floor, he separates the patient's elbow from his side,
and places the heel of his other foot in the axilla, receiving the Heei in the
head of the os humeri upon it, whilst he is himself in the half
sitting posture by the patient's side. He then draws the arm, by
means of the handkerchief, steadily for three or four minutes,
when, under common circumstances, the head of the bone is
easily replaced (see plate) : but if more force be required, the
handkerchief may be changed for a long towel, by which
several persons may pull, the heel still remaining in the axilla. I
392 DISLOCATIONS OF THE OS HUMERI.
generally bend the fore arm nearly at right angles with the os
humeri, because it relaxes the biceps, and consequently diminishes
its resistance. I have, in many cases, extended from the wrist, by
tying the handkerchief just above the hand, but more force is
required in this than in the former mode, although it has this
advantage, that the bandage is less liable to slip. In recent cases
it very rarely happens that this mode of extension fails, and it is
so easily applied in every situation, that I have recommended all
our young men to employ it in the first instance, when called to
this accident.
Second Mode.
Second But iu thosc cascs in which the muscles are of very considerable
strength, and the dislocation having existed for several days, the
muscles have become permanently contracted, so that the limb is
strongly fixed in its new situation, more force is required, and the
following means should be employed. The patient must be placed
Application "pon a chaii*, and the scapula fixed by means of a bandage, which
dage.^ ^"' allows the arm to pass through it ; that which we use at our
hospital is a girt buckled on the top of the acromion, so as to raise
the bandage high in the axilla, and thus enable it more completely
to fix the scapula, which is the principal object to be attended to,
as otherwise all efforts will be inefficient. When I first saw the
mode of reduction adopted thirty-eight years ago, a round towel
was used instead of this bandage, which was placed in the axilla,
and crossed the chest, but it appeared to me that by this means
the lower angle of the scapula alone was fixed, and that the
glenoid cavity was drawn Avith the arm when extension was
made ; I directed, therefore, that the towel should be tied over
DISLOCATIONS OF THE OS HUMERI. 393
the opposite shoulder with a handkerchief, so that it should be
raised in the axilla on the injured side, and thus embrace a larger
surface of the scapula ; but still I found the scapula drawn from
the side with the arm, and therefore had the bandage made as
described (see plate^. A wetted roller is next to be bound around
the upper arm just above the elbow, from which situation it
cannot slip, and upon this a very strong- worsted tape is to be
fastened, in a manner to be described, when speaking of the
reduction of dislocated fingers. The arm should then be raised
at right angles with the body, and if there be much difficulty in
the reduction, it should be elevated above the horizontal line,
more completely to relax the deltoid and supra-spinatus muscles.
Two persons should then draw from the bandage affixed to the
arm, and two from the scapula bandage, with a steady, equal, and
combined force ; jerking should be entirely avoided, and every
aim at quick reduction should be discountenanced : " slowly and
steadily' should be the word of command from the surgeon ;
who, after the extension has been kept up for a few minutes,
should place his knee in the axilla, resting his foot on the chair
upon which the patient sits ; he should then raise his knee by
extending his foot, and placing his right hand upon the acromion,
push it downwards and inwards, when the head of the bone will
usually slip into its natural position. Whilst the extension is
proceeding I have seen a gentle rotatory motion of the arm
diminish opposition of the muscles, and the bone suddenly slip into
its place.
But when a limb has remained a considerable length of time
dislocated ; when the muscles are so powerfully contracted that
E E E
394 DISLOCATIONS OF THE OS HUMERI.
the force of men cannot be so steadily exerted as to reduce the
limb, after several attempts, the minds and bodies of the assistants
becoming fatigued, and their efforts violent and unequal, then we
employ the third mode of reduction,
By means of the PulUes.
Puiiies. And here let it be understood that they are not adopted with a
view of employing a greater force, for that might be obtained by
the aid of more persons ; but they are introduced to enable the
surgeon to employ the force gradually and equally ; to avoid jerks
and unequal extension, which, in protracted cases, the efforts of
men are sure to produce. If, therefore, I saw a surgeon, as soon
as the puUies were fixed, draw them violently, and endeavour sud-
denly to reduce the limb, I should not hesitate at once to say,
" that gentleman is ignorant of the principle upon which this
mechanical power is employed, and has still this part of his
Application profcssiou to Icam." For the application of the pulley, the patient
sits between two staples, which are screwed into the wainscot on
each side of him ; the bandages are then applied, precisely as in
the formed mode, in which the extension is performed hymen,
and the force is applied in the same direction ; the surgeon should
first draw the pulley, as the class of people usually summoned to
his assistance, being ignorant of the principle upon which it is
employed, would use too great violence ; he should draw gently
and steadily, until the patient begins to complain of pain, and
then cease, keeping up the degree of extension, and conversing
with the patient to direct his mind to other objects. In two or
three minutes, more force should be applied, and continued until
I
DISLOCATIONS OF THE OS HUMERI. 395
pain be again complained of, when the surgeon should again
cease to increase the force ; and thus he should proceed for a
quarter of an hour, at intervals slightly rotating the limb. He
should, when he has applied all the extension he thinks right,
give the string of the pulley to an assistant, desiring the existing
degree of extension to be supported ; then, putting his knee in the
axilla, and resting his foot upon the chair, he should gently raise
and push back the head of the bone towards the glenoid cavity,
when the bone will pass into its socket ; this takes place generally
without the snap which is heard when other means are employed,
yet both the surgeon and the patient are aware of some motion of
the head of the bone at the time.* If the pullies be employed as
above, the extension will be conducted infinitely more steadily and
effectually than when performed by men. In my hospital practice The efficacy
I order the patient to be bled, and to be put into a warm bath a tendency to
syncope.
at the temperature of 100° to 110°; and I give him a grain of
tartarized antimony every ten minutes until he becomes faint ;
then I order him to be removed from the bath, to be wrapped in a constitu-
blanket, and immediately placed upon the chair for extension, of assisting
•^ *■ * reduction.
before his muscles have had time to recover, which expedient
lessens the necessity of employing very considerable force. Mr.
Henry Cline, Surgeon to St. Thomas's Hospital, son to my most
excellent master, and who would have made an excellent practical
surgeon if the hand of death had not prematurely deprived the
* One of our pupils, a Mr. Bartlett, of Ipswich, has invented a small spring, by means of which
the strings are attached to the pulley, and which can suddenly detach them whilst the knee is in the
axilla. This instrument may sometimes be useful.
E E E 2
396 DISLOCATIONS OF THE OS HUMERI.
world of his useful talents, was in the habit of directing his pati-
ents to support a weight for a length of time before the extension
was began, with a view of fatiguing the muscles, and lessening
their power of resistance. In apartments where it is not con-
venient to place the pullies in the walls, I have fixed them in the
floor, on each side the patient, who must, under these circum-
Meansof stauccs, sit upoH the floor. When the reduction has been effected,
preventing *
the head of gniall cushiou should be placed in the axilla, and fixed there
the bone '
SSsitu- by a stellate bandage, to prevent the head of the bone again
dbteiy after sliopiu^ from its situatioH, which the excessive relaxation of the
the reduc- llo • ^ -i I'lii
*'""• muscles would readily permit ; but the cushion should not be so
large as to separate the arm far from the side. The sling is to
be also worn to support the arm.
There is still a fourth mode of reducing the dislocation into the
axilla, which is applicable to recent dislocations, to delicate
females, and to very old, relaxed, and emaciated persons, viz. :
Bi/ the Knee in the Amlla.
Fourthmode Thc Daticut is scatcd noon a low chair, the surgeon placing
ofreduction. » ^ O r &
himself by him, separates the dislocated arm from the side suffi-
ciently to admit his knee into the axilla, and resting his foot upon
the side of the chair, he places one hand upon the os humeri, just
above the condyles, and the other upon the acromion scapulae ;
he then pulls down the arm over the knee, and in this manner
reduces the dislocation. (^See plate.^ Even in persons of pow-
erful muscles I have known this mode succeed, when the patient
remained in the state of intoxication, in which he was found when
the accident happened.
I
DISLOCATIONS OF THE OS HUMERI. 397
The Ambe has been recommended for the reduction of disloca- xheuseof
. - , , . . • 1 1 the Ambe.
tions m the axilla, and this instrument was, in the last century,
improved by the addition of a screw for the purpose of rendering-
its extension more gradual. It may succeed very well in recent
cases, and in those persons whose muscles are not very powerful ;
but when a continued extension must of necessity be used to
reduce the bone, as its fixed point of action is upon the ribs of
the patient, it produces too much injury to the side, is too painful
to be borne long, and is, therefore, an instrument which cannot
be recommended for g-eneral use.
Mr. Kirby, surgeon in Dublin, has lately advised an ingenious
mode of applying force in dislocations of the shoulder : the sca-
pula being fixed and the bandage applied to the arm, the patient
sits upon a mattress which is laid upon the floor, and the assist-
ants, to whose management the extension and counter-extension
are consigned, place themselves at his sides, sitting opposite to
each other, and disposing their legs so that the soles of their
feet are opposed to each other, behind and before the patient. If
occasion should require a greater force than the power of two
men, the assistants may be increased by placing one or more at
the backs of the other two, sitting close up to them with their
faces turned towards the patient ; the extension is now made, with
the arm raised nearly to a right angle with the body, and in the
direction forwards or backwards, as the circumstances of the case
may require. The force should be maintained until it is per-
ceived that the head of the bone (which can be easily felt, and
should be pressed upon during the operation), has moved from its
new situation ; and when the head of the bone is found to change
tion.
398 DISLOCATIONS OF THE OS HUMERI.
its position, the assistants should slowly diminish their force while
the surgeon directs it toivards the glenoid cavity, by pressing the
elbow to the side of the patient and slightly raising it.
Slight force When a person has frequently dislocated his shoulder, a very
reductions sliffht cffort is sufficient to restore the limb to its place ; and I
after repeat- ®
eddisioca- l^now a gentleman in the country who frequently has returned the
dislocated head of the humerus into its situation, by walking up to
a gate, reaching over as far as he could, and then holding by one
of its lowest bars, the upper bar of the gate being pressed firmly
into the axilla ; still retaining his hold, he suffers his body to sink
on the other side of the gate, and the head of the bone is thus
pushed into the glenoid cavity ; this mode of reduction is the same
in principle as that of the heel in the axilla, which, as I have
already mentioned, in three fourths of recent dislocations, is the
best for effecting the reduction.
DISLOCATION FORWARDS, BEHIND THE PECTORAL
MUSCLE, AND BELOW THE MIDDLE OF THE
CLAVICLE.
This species of dislocation is much more distinctly marked than
the former. The acromion is more pointed, and the hollow below
it, from the depression of the deltoid muscle, is much more con-
siderable. The head of the os humeri can be readily and distinctly
ihehumeras. f^lt, and evcu secu, in thin persons, just below the clavicle ; and
when the arm is rotated from the elbow, the protuberance wiay be
observed to be obedient to the motions of the arm.
Symptoms.
Situation of
DISLOCATIONS OF THE OS HUMERI. 399
The coracoid process of the scapula is placed on the outer side
of the head of the bone, so that the latter is situated between
the scapula and the sternum, and is covered by the pectoralis
major muscle. The arm is somewhat shortened, and the elbow is
thrown more from the side, and further back, than in dislocation
into the axilla. (See plate.) The axis of the limb is much
altered, being- thrown inward towards the middle of the clavicle.
The pain attending: this accident, is slie-hter than when the head The degree
.... of pain in
of the OS humeri is thrown into the axilla, because the nerves of t^is acci-
dent.
the axillary plexus are less compressed; but the motions of the
joint are much more materially affected ; the head of the bone
becoming- fixed by the coracoid process, and neck of the scapula,
on the outside, and by the clavicle above, while the muscles of the
scapula, as the supra and infra spinati, and teres minor, being put
upon the stretch, confine all its motions inwards and backwards.
If, therefore, the arm be attempted to be brought forwards, the
head of the bone strikes against the clavicle ; if outwards, from
the side, the coracoid process stops it; but its motion backwards
is confined, not by bone, but by the resistance of muscles. But
the strongest diagnostic marks of this dislocation are these : the Diagnostic
head of the bone is below the clavicle ; the elbow is separated
from the side, and thrown backwards ; and the rotation of the
arm gives motion to the head of the bone under the clavicle.
Dissection of the Dislocation Forwards.
The head of the os humeri is, in this accident, thrown on the
inner side of the neck of the scapula, between it and the second
400 DISLOCATIONS OF THE OS HUMERI.
and third ribs. I have had no opportunity of dissecting a recent
accident of this kind, but in the Museum at St. Thomas's Hos-
pital, we liave a beautiful specimen of one in a limb which had
been long dislocated, and which was removed from the shoulder of
a patient by my colleag-ue, Mr. Green, and dissected by Mr. Key,
who has given me the following account of the appearances :
" The head of the bone was thrown on the neck and part of the
venter of the scapula, near the edge of the glenoid cavity, and
immediately under the notch of the superior costa ; nothing
intervened between the head of the humerus and scapula, the
subscapularis being partly raised from its attachment to the
Appearances vcutcr. Thc hcad was situated on the inner side of the coracoid
process, and immediately under the edge of the clavicle, without
having the slightest connexion with the ribs; indeed, this must
have been prevented, by the situation of the subscapularis and
serratus magnus muscles between the thorax and humerus. The
tendons of all the muscles attached to the tubercles of the
humerus were perfect, and are shewn in the preparation. The
tendon of the biceps was not torn ; and it adhered to the capsular
ligament. The glenoid cavity was completely filled up by liga-
mentous structure, still, however, preserving its general form and
character. The tendons of the supra and infra spinatus, and teres
minor muscles, adhered by means of bands to the ligamentous
structure occupying the glenoid cavity ; and to prevent the effects
of friction between the tendons and the glenoid cavity in the
motions of the arm, a sesamoid bone had been formed in the
substance of the tendons. The newly formed socket reached from
the edge of the glenoid cavity to about one third across the venter.
DISLOCATIONS OF THE OS HUMERI. 401
A complete lip was formed around the new cavity, and the surface
was irregularly covered with cartilage. The head of the bone
had undergone considerable change of form, the cartilage being
in many places absorbed. A complete new capsular ligament
had been formed." (See plate.)
The pectoralis minor is not mentioned in this dissection, but
from the natural situation of the coracoid process, into which this
muscle is inserted, it must have passed over the head of the os
humeri, as did the pectoralis major.
The usual causes of this dislocation are, either a fall upon the causes of
•111 1111 • 1 ^ *^'^ disloca-
elbow, or a violent blow upon the shoulder, as m the last described t'«°-
dislocation. If it be a blow upon the elbow which has produced
the accident, it must have been inflicted at a time when the elbow
was thrown behind the central line of the body ; and when the
shoulder received the blow, the head of the bone must have been
driven forwards and inwards.
Reduction of the Dislocation Forwards.
In this, as in the former case, we can usually succeed in effect-
ing reduction by placing the foot in the axilla, and by extending
the arm in the same manner ; excepting that in this dislocation,
the foot is required to be brought more forward to press on the
head of the bone, and the arm should be drawn obliquely down-
wards, and a little backwards ; but in those cases in which some
days have elapsed before reduction has been attempted, continued
extension will be necessary, and to employ it steadily and effect-
ually, the puUies should be used.
F F F
402 DISLOCATIONS OF THE OS HUMERI.
The same bandage is required as in the dislocation in the
axilla, whether the power used be applied through the medium
of pullies or directly by men. The arm should be bent to relax
the biceps muscle ; but the principal circumstance to be con-
sidered is, the direction in which the bone is to be drawn, and
the best direction is slightly downwards ; for if it be drawn
horizontally, the head of the os humeri is pulled against the
coracoid process of the scapula, and a difficulty created which
may be avoided. The principle upon which the pulley is em-
ployed, and the manner in which the extension is supported, is
the same as in the dislocation into the axilla, but the direction
is different, the arm being drawn obliquely downwards and
backwards. The extension must be kept up longer than in the
dislocation downwards, as the resistance is greater ; but as soon
as the bone is felt to move from its situation, the surgeon should
give the strings of the pulley to an assistant, and putting his
knee or heel against the head of the bone at the fore part of the
shoulder, should push it back towards the glenoid cavity ; but this
step is not of the smallest utility until the bone has been drawn
below the level of the coracoid process ; and whilst the surgeon
is thus pressing the head of the bone backwards, he should pull
the arm forwards from the elbow. This is the plan which I
have found by far the most eifectual in reducing the disloca-
tion forwards.
DISLOCATIONS OF THE OS HUMERI. 403
DISLOCATION OF THE OS HUMERI ON THE
DORSUM SCAPULAE.
In this dislocation, the head of the hone is thrown upon the Diagnostic
signs.
posterior surface of the inferior costa of the scapula. It is an
accident which cannot be mistaken, as there is a protuberance
formed by the bone upon the scapula, which immediately strikes
the eye ; and when the elbow is rotated, this protuberance rolls
also. The dislocated head of the bone may be easily grasped
between the fingers, and distinctly felt resting below the spine of
the scapula ; the motions of the arm are impaired, but not to the
same extent as in either of the other states of luxation.
Two cases of this accident have occurred in Guy's Hospital in xheunfie-
•' "^ quent occut-
thirty-eight years; the first during my apprenticeship. It hap- a^^-^g^t*^'^
pened during the anatomical lecture at St. Thomas's Hospital.
The surgery-man came to the theatre and announced that there
was a dislocation of the shoulder at Guy's Hospital, when Mr.
Cline went over with the students to see the accident, and met
Mr. Forster, under whose care the patient was admitted. The
nature of the accident was at once obvious, from the projection of
the head of the bone on the dorsum scapulae. The bandages
were applied in the same manner as if the head of the humerus
had been in the axilla, and the extension was made in the same
direction as in that accident. During the progress of the adjust-
ment of the apparatus, some conversation took place between
Mr. Cline and Mr. Forster, as to what variation in direction there
should be given to the bone, if the first attempt should not
F F F 2
404 DISLOCATIONS OF THE OS HUMERI.
succeed ; but in less than five minutes, the bone slipped into the
glenoid cavity with a loud snap.
The second case, which occurred several years after, was easily
reduced by the dressers, under the same treatment.
Mr. Toulmin, of Hackney, has had the kindness to send me the
following communication upon the subject of this species of dis-
location :
Hackney, July 10, 1822.
My dear Sir,
Mr. Toui- The g-entleman to whom the dislocation of the head of the
min's case, o
humerus upon the dorsum scapulae occurred, was Mr. Collinson,
who was about thirty-six years of age, six feet high, and unusually
muscular. The injury was sustained in the neighbourhood of
Windsor, in consequence of his horse falling with him, by which
he was thrown over the animal's head. He applied to a surgeon
at Windsor, but the character of the accident was not detected.
He returned in a post-chaise to his own house, when Mr. Hacon
and myself saw him. The shoulder had lost its natural roundness;
the arm could be moved considerably, either upwards or down-
wards ; but the motion, either in the anterior or posterior direc-
tion, was very limited. On raising the arm to a right angle
with the side, the direction of the limb was obviously behind the
glenoid cavity; and by placing the hand over the dorsum scapulae,
and then rotating the arm, the head of the bone was felt to obey
the rotating motion.
Means em- Jn Order to rcduce this dislocation, a lar^e towel was applied to
ployed for ^ 53 1 r
itsreduction. gygtain the necessary force for the reduction, and to fix as much as
DISLOCATIONS OF THE OS HUBIERI. 405
possible that part of the scapula unoccupied by the head of the
bone. A gradual extension of the limb was made directly out-
wards, and then the arm being* slowly moved forwards, the head
of the bone was distinctly heard to snap into its socket. The
extension was not continued for more than two or three minutes
before the reduction was accomplished. To the best of my
recollection, Mr. Collinson's arm was perfectly restored to all its
functions within a month.
I am always, my dear Sir,
Very truly your's,
J. TOULMIN.
I have also received the following remarks on the dislocation of
the OS humeri backwards, from Mr. C. M. Coley, of Bridgeworth.
May Uth, 1822.
My dear Sir,
The dislocation of the shoulder backwards is very rare, and
I apprehend, imperfectly understood and described by surgical
writers. The external appearances are a hollow and puckering of
the parts just below the acromion ; the arm lies close to the side ;
the fore-arm is turned inwards, and passes obliquely forwards
across the body ; a protuberance as large as an orange is seen on
the dorsum scapulae, close to the spine of that bone. This dislo-
cation is, I suppose, produced by the action of the teres major
and latissimus dorsi upon the bone, while its head is forced over
the margin of the glenoid cavity.
406 DISLOCATIONS OF THE OS HUMERI.
Reduction.
This is eiFected by elevating* the arm and rotating it outwards,
so as to roll the head of the humerus towards the axilla ; having
brought it as much as possible to resemble a dislocation into the
axilla, the operator must keep it in that situation, and, at the same
time, bring down the arm in an horizontal direction, when, an
extending force being* applied, the bone will be readily reduced.
CASE I.
June 17th, 1820. Thomas Aiding, of this town, was pulled
down by a calf, which he was driving, a cord having been tied to
one of the calf's legs, and held fast by the man's hand. The
appearances corresponded with the above described general marks
of the accident.
Means of Reduction employed.
Means of I rotatcd the fore arm as much as possible outward, carrying'
the whole arm upwards at the same time, so that the hand was
brought nearly in a line with the vertebrae, and as high as it could
be extended above the head. By this expedient I succeeded in
rolling the head of the humerus downwards and inwards, until it
rested on the inferior costa of the scapula, and was in part to be
felt in the axilla. Having thus reduced it as far as possible into
the situation resembling the dislocation downwards, I brought the
arm and fore arm carefully downwards and backwards into the
horizontal line, keeping the head of the humerus in the same
situation all the time. Extension being now made, and my hand
I
DISLOCATIONS OF THE OS HUMERI. 407
being placed firmly on the acromion, the bone was easily replaced.
The rotatory motion produced considerable pain ; and just as the
head of the bone crossed the edge of the glenoid cavity, severe
pain was felt, and a noise was heard. My father and Mr. Cantin
were so kind as to assist me.
CASE TI.
September 24th, 1820. — Jenkins, aged fourteen, was thrown
against a tree by a furious horse, by which accident his shoulder
was displaced backwards. The tumour produced by the head of
the bone was to be seen in a line with the spine of the scapula, and
in part projecting beyond it. The acromion projected very much,
and the integuments below it were puckered and formed a cavity.
Reduction.
I rotated the arm in an extended direction, still outwards, and
raising it as high as I could I brought the head of the displaced
bone towards the axilla ; then retaining the bone in this position,
having carefully brought down the limb into a horizontal line,
Mr. Cantin and I made an extension, and the limb was readily
reduced.
C. M. COLEY.
PARTIAL DISLOCATION OF THE OS HUMERI.
I believe this is not a very rare accident, and it shews itself by
the following marks :
408 DISLOCATIONS OF THE OS HUMERI.
Symptoms. The Head of the bone is drawn forwards against the coracoid
process ; there is a depression opposite the back of the shoulder-
joint, and the posterior half of the glenoid cavity is perceptible,
from the advance of the head of the bone ; the axis of the arm is
thrown inward and forwards ; the inferior motions of the limb are
still capable of being performed; but its elevation is prevented by
the head of the humerus striking against the coracoid process ;
there is an evident protuberance formed by the head of the bone
in its new situation, which is felt readily to roll when the arm is
rotated.
CASE I.
Mr. Brown, aged fifty years, was thrown from his chaise on his
shoulder, and, upon examination after the accident, the roundness
of the shoulder was lost, and there was a hollow under the acro-
mion ; the head of the bone projected forwards and inwards
against the coracoid process ; the arm could be raised from the
side if brought forwards, but with difficulty raised directly up-
wards. By extension of the shoulders backwards, I at last
brought the head of the bone to the glenoid cavity, but it directly
again slipped forwards as the extension ceased. This dislocation
differs from that forwards under the pectoral muscle, in the head
of the OS humeri, being still on the scapular side of the coracoid
process, while in the complete dislocation forwards it is thrown
on its sternal side.
Dissection. The ouly case of dissection of this accident, which I have had
an opportunity of seeing, was the following, for which I am
indebted to Mr. Patey, surgeon in Dorset-street, who had the
i
DISLOCATIONS OF THE OS HUMERI. 409
subject broug'bt to him for dissection, at the anatomical room,
St. Thomas's Hospital.
The following is Mr. Patey's account:
CASE II.
Partial dislocation of the head of the os humeri, found in a Mr. Patey's
ease.
subject brought for dissection to St. Thomas's Hospital, during
the latter part of the year 1 819.
The appearances were as follow : The head of the os humeri, Appearances
11 /» 11- 1 before dis-
on the left side, was placed more forward than is natural, and section.
the arm could be drawn no farther from the side than the half
way to the horizontal position.
Dissection.
The tendons of those muscles which are connected with the Appearances
upon dissec-
joint were not torn, and the capsular ligament was found attached tion.
to the coracoid process of the scapula. When this ligament was
opened, it was found that the head of the os humeri was situated
under the coracoid process, which formed the upper part of the
new glenoid cavity ; the head of the bone appeared to be thrown
upon the anterior part of the neck of the scapula, which was
hollowed, and formed the lower portion of the glenoid cavity.
The natural rounded form of the head of the bone was much
altered, it having become irregularly oviform, with its long axis,
from above downwards; a small portion of the original glenoid
cavity remained, but this was rendered irregular on its surface,
by the deposition of cartilage ; there were also many particles
of cartilaginous matter upon the head of the os humeri, and upon
G G G
410
DISLOCATIONS OF THE OS HUMERI.
the hollow of the new cavity in the cervix scapulae, which received
the head of the bone. At the upper and back part of the joint
there was a large piece of the cartilage which hung loosely into
the cavity, being connected with the synovial membrane, at the
upper part only, by two or three small membranous bands. The
long head of the biceps muscle seemed to have been ruptured
near to its origin at the upper part of the glenoid cavity, for at
this part the tendon was very small, and had the appearance of
being a new formation. (See plate.)
James Patby.
Cause.
Means of
reduction
and of pre-
venting the
recurrence
of the dis-
location.
Dislocation
of the shoul-
der compli-
cated with
fracture.
This accident happens from the same causes which produce the
dislocation forwards. The anterior part of the ligament is torn,
and the head of the bone has an opportunity of escaping forwards
to the coracoid process.
The mode for its reduction will be the same as that for the
dislocation forwards, but it is necessary to draw the shoulders
backwards to bring the head of the bone to the glenoid cavity ;
and immediately when the reduction is completed, the shoulders
should be bound back by a clavicle bandage, or the bone will
immediately again slip forward against the coracoid process.
Dislocations of the shoulder are sometimes complicated with
fracture of the head of the os humeri; and we have a preparation
in the Museum at St. Thomas's Hospital, in which the greater
tubercle at the head of the bone had been broken off, and the os
humeri thrown into the axilla. This complication of accident does
not add to the difficulty of reduction, but, on the contrary, rather
facilitates the return of the bone, as the insertion of the principal
DISLOCATIONS OF THE OS HUMERI, 411
Opponent muscles, the supra and infra spinati, is removed ; but it
increases the difficulty of retaining the bone within the glenoid
cavity after the reduction is completed.
FRACTURE OF THE NECK OF THE OS HUMERI,
WITH THE DISLOCATION FORWARDS, UNDER
THE PECTORAL MUSCLE.
Mr. John Blackburn fell from his horse, many years ago, at
Enfield, and dislocated his shoulder forwards. Mr. Lucas, sen.,
Surgeon of Guy's Hospital, was sent for, who said, after he had
made considerable extension, that the bone was reduced. Five
weeks afterwards Mr. B. came to London, and shewed me his
shoulder, when the appearances of dislocation still remaining, I
advised a further extension, to which he would not consent. I
had frequent opportunities of seeing him afterwards, but the
shoulder exhibited the same appearances of dislocation. He had,
however, the power of using the arm and hand in all directions,
excepting upwards, but could not raise his arm parallel with his
body ; and suffered but little pain or inconvenience.
In June, 1824, he died ; and as he had always promised me the
dissection of his shoulder if I survived him, I removed it in the
presence of Mr. Arnott, Surgeon of Greenwich Hospital, examined
it with great care, and have the bones preserved. The deltoid
teres major and coraco brachialis muscles did not appear to me to
be altered; the supra-spinatus was lessened, as was the teres minor,
G G G 2
412 DISLOCATIONS OF THE OS HUMERI.
which had lost considerably of its natural colour : the infra-spinatus
was stretched ; the subscapularis diminished, and rounded by the
projection of the head of the os humeri, and adhered to its
cartilaginous surface. The capsular ligament was torn under the
subscapularis muscle, but every other part was entire. The head
of the OS humeri had been thrown forwards on the inner side of
the coracoid process, and had been united by bone to the scapula ;
but its cartilage remained under the tendon of the subscapularis.
The neck of the os humeri was broken through, and had been
covered by a granular ligamentous substance ; but the parts were
kept together only by the ligament of the joint, and a new and
very useful joint had been formed. The outer edge of the
glenoid cavity remained ; the surface of the glenoid cavity was
granulated and ligamentous. The greater tubercle of the os
humeri was exceedingly increased, and the tendon of the biceps
passed through the bone. The tubercles were separated with the
body of the bone, and not with its head.
This, then, was a case of fracture of the cervix humeri within
the capsular ligament, terminating in a ligamentous union.
COMPOUND DISLOCATION OF THE OS HUMERI.
Mr. Dixon's Au injury of excessive violence will sometimes occasion the head
of the bone to be forced through the integuments in the dislo-
cation forwards. It happened in the practice of Mr. Saumarez,
case.
DISLOCATIONS OF THE OS HUMERI. 413
and Mr. Dixon, of Newlngton ; and for the following detail of its
circumstances I am indebted to Mr. Dixon.
CASE,
My dear Sir,
T feel pleasure in answering the queries you have put. The
accident happened to Robert Price, fifty-five years of age, who, on
returning in a state of intoxication from the Borough, fell down
upon his shoulder. Upon examination, I found that the head of
the bone having passed through the integuments in the axilla, lay
exposed upon the anterior part of the chest, and situated over the
pectoral muscle on the right side. The reduction of the disloca-
tion was easy, being performed without the necessity of raising
him from the state of stupor and insensibility in which he was
lying, by the usual method of extension and counter-extension,
taking care only to guide the bone into the glenoid cavity ; he
was then put to bed and an evaporating lotion applied. On the
following morning considerable pain and tension had come on;
he was bled, and purged freely ; a large poultice was applied over
the joint, and anodynes were given to lessen pain and procure
sleep ; leeches were frequently applied in the neighbourhood of
the joint for the first ten days or fortnight, after which, a copious
discharge of pus issued from the wound in the axilla. The
constitution now felt the effects of so important an injury; he
became irritable, restless, and lost flesh : healthy pus was dis-
charged freely from the joint for ten or twelve weeks, when it
somewhat abated. A succession of small abscesses, situated in
the cellular membrane, surrounding the joint, were exceedingly
414 DISLOCATIONS OF THE OS HUMERI.
troublesome for several months, some of which formed extensive
sinuses, and required to be freely dilated. The discharge of pus
was kept up from the joint nearly twelve months, when it finally
ceased, leaving" the joint anchylosed, and the wound closed. He
was quite recovered in fourteen months from the accident, at
which time he called on me, and felt gratified, by shewing how
freely he could make use of the fore arm, and handle his pen
for all the purposes of business. He is still living in Paradise-
row, Stockwell, and is employed by the parish of Lambeth as a
collector of assessed taxes.
I am, my dear Sir,
Your's faithfully,
P. DiXON.
Treatment.
Such a case will require an immediate reduction, by the means
which I have described for the dislocation of the os humeri for-
wards ; and, in general, the greater the violence done to the
injured limb, the more easy is the reduction, from the diminution
of the constitutional powers which so great a shock produces.
When the bone is replaced, lint dipped in blood is to be applied
to the wound, or if the wound be large, a suture should be
employed, and then the lint applied ; adhesive plaster should be
used to support approximation, and the limb should be kept close
to the side by means of a roller passed round the body, including
the arm, and thus preventing the least motion of the head of the
bone ; by these means the suppurative inflammation may be
prevented, and the cure may proceed without protracted suffering,
or any danger to the patient's life.
DISLOCATIONS OF THE OS HUMERI. 415
PARTIAL DISLOCATION OF THE OS HUMERI
FORWARDS.
Mr. Bachelor, of Southville, ag-ed thirty-six, fell from a chaise
on the 12th of November, and, as he supposes, pitched on his
shoulder. On rising he could not move his right arm for ten
minutes, when some sudden spasm gave him the power of moving
it underhand. Inflammation succeeded ; the shoulder became
much swollen, with pain down the arm to the fingers, and particu-
larly in the direction of the cubital nerve. On looking at the arm
the same evening, he found that the os humeri appeared to be
advanced.
It is two months since the injury, and the hand is now be-
numbed. There is much pain at the insertion of the biceps into
the fore arm, so that he has been often obliged to rise twice
during the night to put his hand in warm water.
The appearances are a projection of the acromion, and a hollow
beneath it ; the head of the os humeri rests against and under the
coracoid process, and the scapular end of the clavicle is opposite to
the middle of the head of the bone. The biceps muscle was
relaxed and lessened; the coracoid process of the scapula was
with difficulty felt above, and to the inner side of the head of the
OS humeri.
The principle of treatment in these cases is, to oppose the pec-
toralis major by a clavicle bandage, with a broad strap over the
head of the os humeri, and to bring the elbow forward to keep the
head of the os humeri back.
416 DISLOCATIONS OF THE OS HU3IERI.
DISLOCATION OF THE OS HUMERI BACKWARDS.
A man fell from the roof of a coach, and struck the point of
his left shoulder against a projecting stone. He suffered little
pain from the accident, but finding himself incapable of using his
arm, he came immediately to the hospital.
Upon examination, I found that the head of the humerus was
thrown upon the dorsum of the scapula, where it presented a con-
siderable prominence, behind the glenoid cavity, and immediately
under the spine of the bone. The vacancy beneath the acromion
was not so remarkable as in the axillary dislocation. The arm
was closely applied to the side, and slightly inverted, the elbow
being directed rather anteriorly. Free motion was practicable
forward and backward, but the limb could not be raised or
carried across the breast without great difficulty.
Reduction was easily effected in the following manner : The
scapula being fixed, extension was made, by means of a cloth
twisted around the elbow, for about three minutes, when finding
no disposition in the head of the bone to return to the cavity,
although it was already in close contact with its lower and back
margin, I made a fulcrum by my right hand in the axilla, and
grasping the elbow in my left, readily succeeded in lifting it into
its socket.
J. S. Perry.
House Surgeon's Apartments,
St. Bartholomew's Hospital.
DISLOCATIONS OF THE OS HUMERI. 417
Mr. Perry, without solicitation, had the kindness to send
me the foregoing* case, for which I am much indebted to him.
Our large hospitals in London should be made as conducive as
possible to the public advantage, by a liberal and reciprocal
communication.
H H H
FRACTURES near the SHOULDER-JOINT,
LIABLE TO BE MISTAKEN FOR DISLOCATIONS.
FRACTURE OF THE ACROMION.
Diagnostic This point of boiie is sometimes broken ; and in this accident,
symptoms, ^j^gjj ^^g shoulders are compared, the roundness of the injured
side is lost, and part of the attachment of the deltoid muscle being
broken off, the head of the os humeri sinks towards the axilla as
far as the capsular ligament will permit. On tracing* the acromion
from the spine of the scapula to the clavicle, just at their junction,
a depression is felt, from the fall of the fractured portion. If the
distance be measured from the sternal end of the clavicle to the
extremity of the shoulder, it will be found lessened on the injured
side. If the surgeon raises the arm from the elbow, so as to put
the deltoid muscle in motion, the natural form of the shoulder is
directly restored, but the deformity returns immediately when the
arm is again suffered to fall.
This accident is best detected and distinguished from disloca-
tion by raising the arm at the elbow : having restored the figure
FRACTURES NEAR THE SHOULDER-JOINT. 419
of the part, the surgeon places his hand upon the acromion and
rotates the arm, when a crepitus can be distinctly perceived at the
point of the shoulder, and along the superior portion of the spine
of the scapula. The patient, as soon as the accident has happened,
feels as if his arm Avere falling oiF, the shoulder dropping with a
great sense of weight, and there being but little power to raise
the limb.
Fracture of the acromion scapulae will unite by bone, but it Treatment.
generally unites by ligamentous substance, in consequence of the
difficulty which exists in producing adaptation, and in preserving
the limb perfectly at rest during the period required for union.
In the treatment of this accident, the head of the os humeri is the
splint which is employed to keep the acromion in its natural
situation ; and with this view the elbow is raised and the arm is
fixed ; thus the bone will be elevated to the inferior surface of the
acromion, and if it be kept steadily in that position, it will support
and keep in its place the broken process. The deltoid muscle
should be also relaxed, and this is best effected by a cushion
placed between the elbow and the side ; for if the elbow be brought
close to the side, the broken acromion is further separated. The
arm should be raised as much as is possible, and the elbow be
carried a little backwards, and then bound to the chest by a roller;
in this position it should be kept firmly fixed for three weeks,
every thing being done to prevent any motion of the bone. Very
little inflammation succeeds this accident, and the disposition to
ossific union is very feeble in the separated portions of bone.
If a pad be placed in the axilla, the broken portion becomes
H H H 2
420 FRACTURES NEAR THE SHOULDER-JOINT.
widely separated from the spine of the scapula, because it throws
out the head of the os humeri.
FRACTURE OF THE NECK OF THE SCAPULAE.
Symptoms. But the accidcut which is much more liable to be mistaken
for dislocation, is the fracture through the narrow part of the
cervix scapulae, immediately opposite the notch of the superior
costa ; by which the glenoid cavity becomes detached from the
scapula, and the head of the bone falls with it into the axilla ;
the shoulder in this case falls ; there is a hollow below the
acromion from the sinking of the deltoid muscle, and the head
of the OS humeri can be felt in the axilla.
CASE.
A young lady was thrown from a gig, by the fall of the horse,
in the Strand ; and being carried to her house, a surgeon in the
neighbourhood was sent for, who told her the shoulder was dis-
located ; by extension all the appearances of dislocation were
removed, and he bound up the arm. On the following morning
he requested me to see the case, as the arm, he said, was again
dislocated. On examination I found the head of the bone in the
axilla, and the shoulder so fallen and flattened, as to give to
the accident many of the characters of dislocation ; however, by
elevating the shoulder, in raising the arm at the elbow, and the
FRACTURES NEAR THE SHOULDER-JOINT. 421
head of the bone from the axilla, it was immediately replaced ; but
when I gave up this support the limb instantly sunk again. 1
then rotated the elbow, and pressing the coracoid process of the
scapula with my fingers, by grasping the top of the shoulder,
directly felt a crepitus. Having satisfactorily ascertained the
nature of the accident, I placed a thick cushion in the axilla, and
drawing the shoulder into its natural position, secured it by the
application of a clavical bandage, and in seven weeks it became
united without deformity.
The degree of deformity produced by this accident depends upon
the extent of laceration of a ligament which passes from the under
part of the spine of the scapula to the glenoid cavity, and which is
not generally described in anatomical books. If this be torn, the
glenoid cavity and the head of the os humeri fall deeply into the
axilla ; but the displacement is much less if this remain whole.
The diagnostic marks of this accident are three : first, the Diagnostic
marks.
facility with which the parts are replaced; secondly, the immediate
fall of the head of the bone into the axilla, when the extension is
removed ; and thirdly, the crepitus which is felt at the extremity
of the coracoid process of the scapula, when the arm is rotated.
The best method of discovering the crepitus is, for the surgeon's
hand to be placed over the top of the shoulder, and the point of
the fore finger to be rested on the coracoid process; the arm being
then rotated, the crepitus is directly perceived, because the cora-
coid process being attached to the glenoid cavity, and being
broken off with it, although itself uninjured, the crepitus is
communicated through the medium of that process.
422
FRACTURES NEAR THE SHOULDER-JOINT.
Treatment The treatment of this fracture consists in attention to two
dent. principles. The first is to carry the head of the os humeri
outwards ; and the second, to raise the glenoid cavity and arm.
The former is effected by a thick cushion placed in the axilla,
which presses the head of the bone and glenoid cavity outwards,
and this may be confined by the clavicle bandage ; and the latter
is produced by placing the arm in a short sling, and then the
raised head of the os humeri supports the glenoid cavity and
cervix scapulee, and keeps it steadily in its place until union is
produced. The time required for recovery from these accidents
in the adult is, from ten to twelve weeks ; in the very young, all
the motions of the limb are restored in a shorter period, but it is
a long time before the limb recovers its strength.
FRACTURE OF THE NECK OF THE OS HUMERI.
The humerus is sometimes broken just below its tubercles,
through its cervix. I have seen this accident happen both in
Age. old and in young persons, but it rarely occurs in middle age. In
the young it happens at the junction of the epiphysis, where the
cartilage is situated ; and in the old it arises from the greater
Symptoms, softucss of this part of the bone. In this fracture the head of
the bone remains in its place, but the body of the humerus sinks
into the axilla, where its extremity can be felt; and it draws
down the deltoid muscle, so as to lessen the roundness of the
shoulder. Just as I was writing this account, a child was
FRACTURES NEAR THE SHOULDER-JOINT. 423
brought into Guy's Hospital with this accident, and I made the
following notes of it ;
Its ag-e was ten years. The symptoms of the injury were
inability of moving the elbow from the side, or of supporting the
arm, unless by the aid of the other hand, without great pain.
The tension which succeeded filled up the hollow which was
at first produced by the fall of the deltoid muscle. When the
head of the bone was fixed, the fractured extremity of the body
of the humerus could be tilted under the deltoid muscle, so
as to be felt, and even shewn, by raising the arm at the elbow.
Crepitus could be perceived, not by rotating the arm, but by
raising the bone and pushing it outwards. The cause of the
fracture was a fall upon the shoulder into a saw-pit of the depth
of eight feet.
It is in old persons that this accident is most liable to be
mistaken for dislocation ; for in them the flexibility of the joint
is much diminished by it, and the changes of position of the bone
are less easily produced.
The best diagnostic marks are the following : Embrace the oi
lagnostic
symptoms.
head of the os humeri with the fingers and fix it, then rotate
the arm at the elbow, and it will be found that the head of
the bone does not obey the rotatory motion, as it is separated
from the body of the humerus by the fracture, which is, in this
case, external to the capsular ligament. The bone in these cases
unites in from three to six weeks, according to the age of the
patient.
The treatment consists in applying a roller from the elbow to Treatment.
the shoulder-joint, in placing a splint on the inner and on the
224 FRACTURES NEAR THE SHOULDER- JOINT*
outer side of the arm, and in confining- these by means of a roller.
A cushion is then to be placed in the axilla, to throw out the
head of the bone, and the arm is to be gently supported by a
sling' ; for if it be much raised, the bones will overlap, and the
union will be deformed.
CASE,
January, 1823.
William Mills, aged seventy-two, fell down during the severe
frost upon his shoulder, three days after which he was admitted
into Guy's Hospital. The arm and shoulder were much swollen,
there was also acute pain and discolouration of the integuments.
Crepitus could not be felt ; and, from the degree of swelling, it
was impossible to ascertain the precise nature of the accident.
Leeches and evaporating lotions were applied. The shoulder was
again examined on the second day, after the swelling had some-
what subsided, and a fracture of the neck of the humerus was
discovered. The pain and swelling again became greater, and
gradually increased ; the integuments inflamed, having- the appear-
ance of erysipelas ; the skin became discoloured and gangrenous.
He was feverish and irritable, then delirious, and gradually sunk
on the tenth day from the accident.
Appearances found on Dissection.
The integuments and cellular membrane, on the inner part of
the shoulder over the clavicle, were considerably thickened, having
a sloughy appearance ; and on cutting through the deltoid muscle,
a large quantity of bloody matter, mixed with serum, was effused.
FRACTURES NEAR THE SHOULDER-JOINT. 425
The capsular ligament was extensively lacerated, the humerus
was fractured through the cervix, also obliquely through the
head ; and a small spicula of bone was separated from the
cervix.
James Mash,
Dresser to Mr. Forster.
I I 1
STRUCTURE OF THE ELBOW-JOINT.
Bones.
This joint is composed of three bones : The lower extremity of
the humerus, the upper part of the ulna, and the head of the
radius. The extremity of the os humeri is expanded, and presents
two lateral eminences, which are called its condyles, the internal
of which is the most prominent ; between these condyles the
articular surface for the ulna is situated, which is in the form of a
pulley, and above it, both anteriorly and posteriorly, is situated a
deep cavity with a thin partition intervening. On the lower
extremity of the external condyle is placed an articular surface,
on which the head of the radius is received. The upper extremity
of the ulna forms two processes, with an articulatory surface
between them, which is adapted to the pulley-like articular surface
of the OS humeri : both these surfaces of the ulna and humerus
are covered with cartilage. The superior and posterior process
of the ulna is called the olecranon, which forms the point of the
elbow, and into which the triceps muscle is inserted ; the anterior
and smaller process is called the coronoid, which gives insertion
STRUCTURE OF THE ELBOW-JOINT. 427
to the brachialis internus. When the arm is extended, the point
of the olecranon is received into the posterior cavity, between the
condyles of the humerus ; and when it is flexed, the coronoid
process passes into the anterior hollow ; so that these cavities are
formed for the purpose of admitting* of free extension and flexion
of the arm. The head of the radius is rounded, and rests upon
the broad articular surface of the humerus, upon which it bends ;
and on its inner side it is received into an articular cavity on the
radial side of the coronoid process of the ulna, upon which the
radius rolls ; and thus all the motions of the fore arm are per-
formed : immediately below its head the radius becomes smaller,
and this part is called its cervix ; at the distance of an inch below
its head is seated a process which is called its tubercle.
The ligaments which bind these bones together are the cap- Ligaments.
sular, which is united with the condyles, and with the portion capsular.
of bone above the cavities of the os humeri; it passes over the
extremity of the humerus, and is united behind to the olecranon,
and to the coronoid process, on the fore part of the ulna ; it is also
connected to the coronary ligament of the radius : this ligament
posteriorly is loose and slender, but on the fore part it is of
considerable strength.
The coronary ligament surrounds the bead of this radius ; it coronary.
is connected above with the capsular ligament, and below with
tlie neck of the radius, by a thin ligament of sufficient length to
allow of rotation of the head of the bone ; it is also attached to
the fore and back part of the coronoid process of the ulna, at its
lateral articulatory surface, and thus firmly unites the radius with
the ulna, yet allows of the rotation of the former.
I I I ^
428 STRUCTURE OF THE ELBOW-JOINT.
Brachio There are four peculiar lio^aments ; first, the brachio cuhitaL or
cubital. ^ ^ ^
internal lateral ligament, which passes from the internal condyle
of the OS humeri into the coronoid process of the ulna.
Brachio Sccoudly, the brachio radial, or external lateral ligament, which
radial.
is fixed to the external condyle of the humerus, and to the
coronary ligament of the radius ; these ligaments give to the
joint a strong lateral support.
Oblique. The third ligament is the oblique, which passes from the coro-
noid process of the ulna to the radius, just below its tubercle;
and it is this ligament which limits the rotation of the radius.
A ligament also reaches from the inner side of the coronoid
process to the olecranon ; and when this latter process is broken
off, it is this ligament, in some instances, which prevents its
extensive separation.
Muscles. The muscles of the joint are, first, the brachialis internus,
which passes over the anterior part of the condyles and capsular
ligament, to which it is attached ; it is inserted in an oblique
direction into the coronoid process, and into the body of the ulna
just below it. The use of this muscle is to bend the fore arm,
and give support to the elbow-joint, by strengthening the capsular
ligament. The next muscle is the triceps^ which arises by one
of its heads from the inferior costa of the scapula, and by its two
others from the os humeri ; it descends to the capsular ligament,
to the loose portion of which it adheres, and is inserted into the
point of the olecranon. This muscle extends the arm, and draws
up and supports the capsular ligament. Thirdly, the anconeus,
which arises from the back part of the external condyle of the
humerus, adheres to the capsular ligament, and is inserted to the
STRUCTURE OF THE ELBOW-JOINT. 429
extent of an inch and a half into the body of the ulna, directly
below the olecranon ; the course of this muscle is oblique ; and
whilst it extends the arm, it supports the capsular ligament. The
biceps muscle does not protect the ulna joint, but has great
influence in preventing a dislocation of the radius forwards, in
the extended state of the arm. It is not connected with the
capsular ligament, as the other muscles are ; but arising from
the glenoid cavity, and coracoid process of the scapula, tendinous,
it becomes fleshy in its middle, and again forms a tendon at the
elbow-joint, which is fixed into the tubercle of the radius. This
muscle bends the fore arm, rotates the radius outwards, that is,
supines the hand, and compresses the capsular ligament opposite
the head of the radius.
DISLOCATIONS OF THE ELBOW-JOINT.
There are five species of dislocation of this joint :
First, both bones are dislocated backwards.
Secondly, both are dislocated laterally.
Thirdly, the ulna is dislocated separately from the radius.
Fourthly, the radius alone is dislocated forwards : and
Fifthly, the radius is dislocated backwards.
DISLOCATION OF BOTH BONES BACKWARDS.
This dislocation is strongly marked by the great change which
Symptoms. 1^ produccd lu the form of the joint, and by its partial loss of
motion. The shape of the elbow is altered, as there is consider-
able projection posteriorly formed by the ulna and radius above
the natural situation of the olecranon. On each side of the
olecranon appears a hollow. A considerable hard swelling is
I
1
DISLOCATIONS OF THE ELBOW-JOINT. 431
felt at the fore part of the joint, immediately behind the tendon
of the biceps muscle, formed by the extremity of the humerus ;
the hand and fore arm are supine, and cannot be rendered entirely
prone. The flexion of the joint is also in a great degree lost.
Dissection of this Dislocation.
T have had an opportunity of dissecting a compound dislocation Dissection
of this ioint, where the radius and ulna were thrown backwards, location
*' ' backwards.
and it is preserved in the Museum at St. Thomas's Hospital.
(See plate.) The coronoid process of the ulna was thrown into
the posterior fossa of the os humeri, and the olecranon projected
at the back part of the elbow, above its usual situation, an inch
and a half; the radius was placed behind the external condyle of
the OS humeri, and the humerus was thrown forwards on the
anterior part of the fore arm, where it formed a large projection.
The capsular ligament was torn through, anteriorly, to a great
extent. The coronary ligament resiiained entire. The biceps
muscle was slightly put upon the stretch, by the radius receding;
but the brachialis internus was excessively stretched by the altered
position of the coronoid process of the ulna. (See plate. ^
This accident usually happens in a fall when a person puts cause of the
out his hand to save himself, the arm not being perfectly ex-
tended, so that the bones are forced back behind the axis of
the OS humeri, by pressure of the whole weight of the body
upon them.
This dislocation is easily reduced by the following means. The
432 DISLOCATIONS OF THE ELBOW-JOINT.
patient is made to sit down upon a chair, and the surgeon, placing
his knee on the inner side of the elbow-joint, in the bend of the
arm, and taking hold of the patient's wrist, bends the arm ; at
the same time he presses on the radius and ulna with his knee, so
as to separate them from the os humeri, and thus the coronoid
process is thrown from the posterior fossa of the humerus ; whilst
this pressure is supported by the knee, the arm is to be forcibly,
but slowly bent, and the reduction is soon effected. It may be
also accomplished by placing the arm around the post of a bed,
and by forcibly bending it while it is thus confined. I have also
reduced the limb by making the patient, whilst placed upon an
elbow-chair, put his arm through the opening in its back, and
then, having bent the arm, the body and limb being thus well
fixed, the reduction was easily eff*ected.
This dislocation is sometimes undiscovered at first, in conse-
quence of the great tumefaction which immediately succeeds the
injury; but this circumstance does not prevent the reduction, even
at the period of several weeks after the accident : for I have
known it then effected by bending the limb over the knee, even
without the application of very great force.
After.treat- As soou as the rcductiou has been accomplished, the arm
should be bandaged in the bent position ; evaporating lotions
should be applied, and the limb be supported in a sling ; the
fore arm should be bent at rather less than a right angle with
the upper arm. A splint may be placed in the sling, for the
better support of the limb.
ment
DISLOCATIONS OF THE ELBOW-JOINT. 433
COMPOUND DISLOCATION OF THE OS HUxMERI AT
THE ELBOW- JOINT.
William Dowson, aged thirteen, was admitted into the accident
ward of Guy's Hospital on the 5th of November, 182'2, at twenty
minutes past seven o'clock in the evening, with compound dislo-
cation of the elbow-joint, occasioned by the overturning of a cart
in which he was riding, and which fell with great violence upon
the elbow of the left arm.
The appearances were as follow : The condyles of the humerus
were thrown inwards through the skin ; the articulating surface
receiving the sigmoid cavity of the ulna being completely exposed
to view ; the ulna was dislocated backwards, and the radius out-
wards ; the lateral and capsular ligaments were torn asunder, with
extensive laceration of the parts about the joint, but the artery
and nerve remained perfectly free from injury.
By the kind assistance of Mr. Key the reduction was easily
effected in the following manner: The humerus being firmly
grasped above its condyles, making that part a fixed point, we
gradually extended the fore arm from the position in which it was
found (at right angles), and the parts returned to their relative
situation ; but upon slightly moving the fore arm, they became
displaced as before ; but the reduction was effected a second time
as above described, and in the semiflexed position the arm was
dressed with adhesive plaster, and a pasteboard splint put on,
previously dipped in warm water, so as to give it pliability in order
to adapt it to the form of the part ; a roller Avas then applied, and
K K K
434 DISLOCATIONS OF THE ELBOW-JOINT.
a sling was attached to the wrist and conveyed round the neck, by
which means the patient was prevented from moving the arm from
the posture in which it was placed. He was then laid recum-
bent, with the elbow resting on a pillow; and the evaporating
lotion of our hospital was employed, to keep the parts constantly
moist and cool. I saw him during the night, and found that he was
generally composed, and had slept. Early the next morning he
was free from pain, his pulse 112; he experienced much thirst dur-
ing the day, without any other unpleasant symptoms, except some
tension of the parts, by no means considerable. On the following
morning, there being some symptoms of inflammation, accom-
panied with pain in the head, I drew from the right arm ten
ounces of blood, which appeared to relieve him ; in the evening of
the same day he was restless, and complained of great thirst ;
small quantities of barley water were given to him, and in the
evening three grains of hydrag : submur. He slept during the
night, and on the following morning the pulse had risen to 121 ;
febrile action appearing, the julepum amnion : acet : was given to
him every three or four hours, and in the evening his pulse had
fallen to 109 ; he complained of darting pains in the shoulder, and
his bowels being in a constipated state, I gave him 35 of ol : ricini,
and two hours afterwards he had a copious evacuation, from which
he felt easier and much relieved, and he passed a good night. On
the following day I found him free from pain and much better.
The next day (Sunday) he complained of slight pains in the upper
arm, accompanied with a small discharge from the wound. On
the following day he was better, pulse 105 ; and on Tuesday the
discharge had increased, but on the three following days it
DISLOCATIONS OF THE ELBOW-JOINT. 435
decreased, when I ventured to dress the wound : the granulations
were extremely healthy, the parts appeared to be well adjusted,
leaving only a small sinus, by which the discharge escaped. It
was again dressed as at first, with the exception of the splint : the
lotion was discontinued, the parts being perfectly cool, and the
tension much reduced. The bowels being confined, the ol : ricini
was repeated, which procured him two stools. On the following
day he complained of pains in the shoulder ; the discharge was
again increasing ; but on the four following days he proceeded
well, the pulse varying from 98 to 109. On the sixth day from
the first dressing I proceeded to repeat that operation ; the granu-
lations were rather prominent, but healthy ; and the wound was
dressed with straps of soap cerate ; during the six following days
the patient continued to get better ; but on the seventh day from
the second dressing of the wound some inflammation appeared,
and the lotion was renewed ; the discharge at this time was very
slight. On examining the part, an abscess had formed upon the
external condyle, which 1 relieved in a day or two after by the
lancet : the quantity of matter discharged was about sij, but quite
healthy. The next day he was much better ; and from this time
he continued improving until the 24th of December, on which day
he was able to leave his bed, and walk about the ward. By great
attention to the use of passive motion, he is now enabled to move
the joint to a considerable extent.
Samuel White,
Dresser at Guys Hospital.
I frequently witnessed the progress of this case with the greatest
pleasure. A. C.
K K K 2
436 DISLOCATIONS OF THE ELBOW-JOIi\T.
LATERAL DISLOCATION OF THE ELBOW.
Natureofthe ^^^ ^^^® ^^^^ ^^^^ uliia, iHstead of being thrown into the posterior
fossa of the os humeri, has its coronoid process situated on the
back part of the external condyle of the humerus. The projection
of the ulna backwards is, in this case, greater than in the former
dislocation, and the radius forms a protuberance behind and on
the outer side of the os humeri, so as to produce a hollow above
it ; the rotation of the head of the radius is distinctly felt by rolling
the hand. Sometimes the ulna is thrown upon the internal condyle
of the OS humeri, so as to produce an apparent hollow above it ;
the rotation of the head of the radius is distinctly felt by rolling
the hand. Sometimes the ulna is thrown upon the internal condyle
of the OS humeri, but it still projects posteriorly, as in the external
dislocation ; and then the head of the radius is placed in the
posterior fossa of the humerus. The external condyle of the os
humeri in this case projects very much outwards. I have never
had an opportunity of dissecting this injury.
,,,, The manner in which the lateral dislocation is produced is the
Causes of the r
accident, game as in that directly backwards, but the direction of the fall is
varied ; it is also caused by the wheel of a carriage passing over
the arm whilst it is placed upon uneven ground. The reduction
of each may be effected as in the former dislocation, by bending
the arm over the knee, even without particularly attending to
the direction of it inwards or outwards ; for as soon as the radius
and ulna are separated from the os humeri by the pressure of the
knee, the muscles give them the proper direction for reduction.
DISLOCATIONS OF THE ELBOW-JOINT. 437
But the bones may be more easily reduced in a recent injury in
the following' manner :
CASE.
A lady consulted me respecting- a fracture of the patella, which
had united by a long ligament ; and I told her to be careful to
wear a bandage, as she was very liable to fall and to break the
other patella, which I have frequently known to happen. This
was at ten o'clock in the morning ; at two o'clock she came to me
at Guy's Hospital, having her elbow dislocated backwards, and
also laterally inwards. Finding that the tendon of the biceps, and
(as I knew) the brachialis internus, were put upon the stretch,
I thought I might make use of them to draw the os humeri back-
wards, as by the string of a pulley, and I forcibly extended the
arm, when the dislocation was immediately reduced.
The plate of the dislocation backwards will explain the mode
in which the reduction was effected. It will be there seen that
the tendon of the brachialis internus is stretched over the condyles
of the humerus, and the biceps is also stretched over that bone ;
so that if the fore arm be forcibly extended, these muscles force
back the condyles of the humerus into their natural situation.
DISLOCATION OF THE ULNA BACKWARDS.
The ulna is sometimes thrown back upon the os humeri without sympt
being followed by the radius. The appearance of the limb is
;oms
of this' ,
accident.
438
DISLOCATIONS OF THE ELBOW-JOINT.
then much deformed by the contortion inwards of the fore arm
and hand. The olecranon projects, and can be felt behind the os
humeri. Extension of the arm is impracticable, but by a force
which will reduce the dislocation, and it cannot be bent to more
than a right angle. It is an accident somewhat difficult to detect;
but its distinguishing marks are the projection of the ulna, and
the twist of the fore arm inwards.
We have an excellent specimen of this accident in the Museum
at St. Thomas's Hospital. (See plate. ^ It had existed a great
Dissection. \ Icugth of time without reduction ; the coronoid process of the
ulna was thrown into the posterior fossa of the humerus ; the
olecranon is seen projecting behind the os humeri ; the radius
rests upon the external condyle, and has formed a small socket for
its head, in which it was able to roll. The coronary and oblique
ligaments had been torn through, and also a small part of the
interosseous ligament ; the lower extremity of the internal condyle
of the humerus seems to have had an oblique fracture in it; but
I doubt whether it had been broken, or only altered in form, on
account of the unnatural position of the ulna. If it had been
broken, it was re-united ; the triceps was thrown backwards, and
the brachialis internus muscle was stretched under the extremity
of the humerus. The accident arises from a severe blow on the
lower extremity of the ulna, by which it is pushed suddenly
upwards and backwards.
This dislocation is more easily reduced than that of both bones ;
and the best method is to bend the arm over the knee, and to
draw the fore arm downwards ; the reduction will then be easy,
as not only the brachialis muscle will act in resistance, but the
Cause.
Mode of
reduction.
DISLOCATIONS OF THE ELBOW-JOINT. 439
radius, resting against the external condyle, will push the os
humeri backwards upon the ulna when the arm is bent.
DISLOCATION OF THE RADIUS FORWARDS.
This bone is sometimes separated from the ulna at their junction
at the coronoid process, and its head is thrown into the hollow
above the external condyle of the os humeri, and upon the coronoid
process of the ulna. (See plate.)
1 have seen six examples of this accident : its symptoms are as Symptoms
^ . . " J ^ of this
follows : The fore arm is slightly bent but cannot be brought accident.
to a right angle with the upper, nor can it be completely extended.
When it is suddenly bent, the head of the radius strikes against
the fore part of the os humeri, and produces so sudden a stop to
its motion, as at once to convince the surgeon that one bone
strikes against the other. The hand is placed in a prone position,
but neither its pronation nor supination can be completely per-
formed, although its pronation be nearly complete. If the thumb
be carried into the fore and upper part of the elbow-joint, the
head of the radius may be there felt ; and if rotation of the
hand be attempted, the bone will be perceived to roll ; this last
circumstance, and the sudden stop to the bending of the arm, are
the best diagnostic marks of the injury.
In the dissection of this case, the head of the radius is found Dissection.
resting in the hollow above the external condyle of the os humeri ;
the ulna is in its natural situation. The coronary ligament of the
440 DISLOCATIONS OF THE ELBOW-JOINT.
radius, the oblique ligament, and the fore part of the capsular, as
well as a portion of the interosseous ligament, are torn through ;
the laceration of the latter ligament allows the separation of the
two bones. The biceps muscle is shortened ; and those who have
not seen an example of this injury, will do well to consult the
preparation from which this plate is taken.
acddenr'''^ Thc cause of this accident is a fall upon the hand when the arm
is extended ; the radius receiving the weight of the body, is forced
up by the side of the ulna, and thrown over the condyle, and upon
the coronoid process of the ulna.
Case. The first case I saw of this accident was in a woman, who was
a patient of Mr. Cline's, in St. Thomas's Hospital, whilst I was an
apprentice to him. The most varied attempts, which his strong
judgment could direct, were made to reduce the bone, but it could
not be replaced ; and the woman was discharged from the hospital
with the dislocation unreduced.
The second case was in a lad to whom I was called by
Mr. Balmanno, of Bishopsgate - street ; and although I inade
attempts, by continuing and varying the extension in every
direction for an hour and a quarter, I could not succeed in effect-
ing the reduction.
The third case was that of a bair-dresser, who, having been
intoxicated in the evening, came to my house on the following
morning with his radius dislocated ; during the time of exami-
nation the patient became faint, and at last fell upon the floor
in a state of syncope ; this I thought afforded me a most
favourable opportunity for replacing the bone, and whilst he was
still upon the floor J rested his olecranon upon my^foot, so as to
1
DISLOCATIONS OF THE ELBOW-JOINT. 44]
prevent the ulna from receding, and then extended the fore arm,
and under these favourable circumstances the radius returned to
its natural situation.
The fourth case was that of a gentleman in Old Broad-street, to
whom I was called by Mr. Gordon, of Oxford-court, in the City ;
and the manner in which we succeeded in the reduction was as
follows : We placed our patient upon a sofa and bent his arm
over the back of it, and then making extension from the hand
without including the ulna, the os humeri being fixed by the sofa,
the radius in a few minutes slipped into its place.
The fifth case was that from which was made the preparation
preserved in our collection at St. Thomas's, and of which I
have given a plate : that preparation was one morning lying on
my chimney-piece, when a gentleman of high character at the bar
called upon me ; he said, " What have you here .-'" and when I
mentioned the nature of the injury, "Well, that is very curious,"
said he, "for I have myself been the subject of this accident." He
then exposed his arm, and shewed me a dislocation of the radius ;
it had happened many years before, and he told me that numerous
and most violent attempts had been made to reduce it without
success.
The observations here stated upon this subject T have usually
given in my lectures, carefully explaining the difficulty in restoring
the bone to its situation ; once, on an occasion of this kind, Mr.
Williams, one of the most intelligent of my pupils, said to me,
"I have known the radius reduced in these accidents by extending
from the hand only." From a consideration of what he said, and
from an experiment on the dead body, placing the radius in the
L L L
442 DISLOCATIONS OF THE ELBOW-JOINT.
situation in which it is thrown by this accident, I was convinced
that the mode of extension mentioned by Mr. WilHams was the
best; as, from the connection of the hand with the radius, that
bone alone is acted upon, and the uhia being excluded from the
force applied, the radius sustains the whole extension. It is also
right in making the extension to render the hand supine, as this
position draws the head of the radius from the upper part of the
coronoid process of the ulna, upon which it would otherwise be
directed; and then to draw the fore arm, by pulling the hand, and
by fixing the os humeri.
Mr. Tyrrel informed me that a sailor, about thirty years of age,
came to St. Thomas's Hospital, as an out-patient, with a disloca-
tion of the radius forwards, which had happened between six and
seven months before. The head of the radius could be distinctly
felt upon the anterior part of the humerus, especially when the
arm was bent as much as the nature of the accident would allow,
and when the hand was bent as much as it could be towards the
fore arm. The position of the limb was half supine ; and when
the humerus was fixed, the hand could be rendered neither per-
fectly supine nor prone. On the attempt to flex the fore arm,
a sudden check to its motion was produced by the head of the
radius striking against the humerus. From constant use of the
arm after the accident, considerable motion had been reacquired,*
yet the man was anxious that an attempt should be made to
reduce it, from which he was dissuaded, and he went to Guy's
Hospital, where the same advice was given to him.
* For he could, although with great difficulty, touch the lips with his hand.
DISLOCATIONS OF THE ELBOW-JOINT. 443
DISLOCATION OF THE RADIUS BACKWARDS.
This is an accident which I have never seen in the living Appearance
1 . I . /. 1 oi^t 1 1 p T ofthisacci-
person; but in the winter or Io21, a man was broiight tor clis- dent,
section into the theatre of St. Thomas's Hospital, in whom was
found this dislocation, which had never been reduced. The head
of the radius was thrown behind the external condyle of the os
humeri, and rather to the outer side of the lower extremity of
that bone. Mr. Sylvester, from Gloucester, a very intelligent
student, had the kindness to make me a drawing of the parts as
they were dissected, and the appearances will be seen in plate
XX vi. When the arm was extended, the head of the radius could
be seen, as well as felt, behind the external condyle of the os
humeri. On dissecting the ligaments, the coronary ligament was
found to be torn through at its fore part, and the oblique also had
given way. The capsular ligament was partially torn, and the
head of radius would have receded much more, had it not been
supported by the fascia, which extends over the muscles of the
fore arm.
Of the causes of this accident I know nothing, never having
seen it in the living subject.
As to its reduction, it will be easily effected by bending the arm; Mode of re-
but to secure the bone from subsequent displacement, the arm must
be kept steadily bent at right angles, and secured by splints and a
circular bandage in that situation, until the union of the coronary
ligament has been effected, which will require the lapse of three
or four weeks from the accident.
L L L 2
444
DISLOCATIONS OF THE ELBOW-JOINT.
LATERAL DISLOCATION OF THE RADIUS.
Mr. Freeman, Surgeon, of Spring-gardens, brought to my
house a gentleman of the name of Whaley, aged twenty-live years,
whose poney having run away with him, when he was twelve
years of age, he had struck his elbow against a tree whilst his arm
was bent and advanced before his head. The olecranon was
broken, and the radius dislocated upwards and outwards, above
the external condyle ; and when the arm is bent, the head of the
radius passes the os humeri. He has an useful motion of the arm,
but neither the flexion nor the extension is complete.
FRACTURES OF THE ELBOW-JOINT.
FRACTURES ABOVE THE CONDYLES OF THE
HUMERI.
The condyles of the os humeri are sometimes obliquely broken
off just above the joint, and the appearance produced is so similar
to that of the dislocation of the radius and ulna backwards, that
this fracture is very liable to be mistaken for that injury. The
following case will best exemplify its diagnostic marks.
CASE.
William Law, aged nine years, was admitted into Guy's Hospital
on the 3rd of July, 1822, with a fracture of the condyles of the os
humeri above the elbow-joint, which he had sustained in being
thrown from a cart, having fallen upon his elbow. At the time
of his admission the arm was slightly bent, and the radius and
ulna appeared to project considerably backwards ; just above
the projection there was a hollow in the back of the arm, so
446
FRACTURES OF THE ELBOW- JOINT.
that the appearances much resembled those of dislocation. I
extended the fore arm, and the appearances of the dislocation
ceased ; but when the extension was discontinued, those appear-
ances returned. At this time Mr. Key arrived, who explained
the accident to be a fracture above the condyles. The arm
Avas put in splints, which were continued to be worn until the
13th of July, when they were occasionally removed, and passive
motion was employed.
D. B. Major,
Dresser, Guys Hospital.
Diagnostic
marks of the
nature of this
accident.
The period
of life at
which the
accident
happens
most fre-
quently.
Treatment.
The appearances of this accident, as will be seen, are like
those of dislocation of the radius and ulna backwards ; and the
mode of distinguishing the two injuries is, by the removal of
all the marks of dislocation on extension, and by their return
so soon as the extension is discontinued ; in general, also, these
accidents are detected by rolling the fore arm upon the humerus,
when a crepitus may be felt just above the elbow-joint.
This fracture happens at all periods of life, but much more
frequently in children than in persons of more advanced age.
Its treatment consists in bending the arm, and drawing it
forwards to eifect replacement ; then a roller should be applied
while it is in the bent position. The best splint for it is one
formed at right angles, the upper portion of which should be
placed behind the upper arm, and the lower portion under the
fore arm ; a splint must also be placed upon the fore part of the
upper arm, and both should be confined by straps ; evaporating
lotions should be used, and the arm kept in a bent position by a
FRACTURES OF THE ELBOW-JOINT. 447
sling. Ill a fortnight, if the patient be young", passive motion
may be gently begun to prevent the occurrence of anchylosis;
and in the adult, at the end of three weeks, a similar treatment is
to be pursued. But even after the most careful and judicious
means which can be adopted, there is sometimes considerable loss
of motion ; and when the accident has not been understood, or
has been carelessly treated, the deformity and loss of motion
become very considerable. (See plate.)
FRACTURE OF THE CONDYLES OF THE OS
HUMERI.
Portsea, March 5th , 1823.
Dear Sir,
Allow me to recommend to you the bearer, Mrs. Hewett, of
Southsea, who met with a severe accident on the 21st of Septem-
ber last, by a fall from a chaise, which occasioned a compound
fracture of the left arm as follows: The external and internal
condyles were fractured longitudinally; the intermediate space
which receives the olecranon was quite comminuted, and three
pieces of bone were extracted soon after the accident from the
external wound : there was also a transverse fracture about two
inches and a half above the condyles.
Evaporating lotions were applied during the two first weeks,
and the case proceeded favourably. I more particularly call your
attention to the wrist of the right arm, which was much injured
448 FRACTURES OF THE ELBOW-JOINT.
at the time of the accident ; I recommended friction, which I am
afraid has been neglected.
If time will permit, your opinion of the above case will much
oblige
Your's respectfully,
Thomas Ivimy.
This lady has, in a great degree, reacquired the flexion and
extension of the left arm.
A. C.
FRACTURE OF THE INTERNAL CONDYLE OF THE
OS HUMERI.
The internal condyle of the humerus is frequently broken
obliquely from the other condyles and body of the bone ; and the
symptoms by Avhich the accident is known are as follow :
First. The ulna appears dislocated, from it and the broken
condyle, projecting behind the humerus when the arm is extended.
Secondly. The ulna resumes its natural situation in bending
the arm.
Thirdly. By grasping the condyles, and bending and extending
the fore arm, a crepitus is perceived at the internal condyle.
Fourthly. When the arm is extended, the lower end of the os
humeri advances upon the ulna, so as to be felt upon the anterior
part of the joint.
I saw a girl, a patient of Mr. Steel, of Berkhampstead, who, by
FRACTURES OF THE ELBOW-JOINT. , 449
a fall upon her elbow, had fractured the olecranon, and also
broken the internal condyle of the os humeri, the point of the
broken bone having- almost penetrated the skin ; the cubital nerve
had been also injured ; for the little finger, and half the ring
finger, were benumbed.
The cause of this accident is a fall upon the point of the elbow.
It usually occurs in youth, before the epiphysis is completely
ossified ; although I have seen it, but less frequently, in age. It
is often mistaken for dislocation.
Its treatment consists in applying a roller around the elbow- Treatment.
joint, to keep the bone in complete apposition ; in wetting it
frequently with spirits of wine and water; in bending the limb
at a right angle, and supporting it in a sling ; and in beginning
with passive motion, in the child, at the expiration of three weeks
after the accident, and at a month in the adult, to prevent the
loss of motion in the joint.
FRACTURES OF THE EXTERNAL CONDYLE OF
THE OS HUMERL
This accident is readily detected by the following symptoms :
Swelling upon the external condyle, and pain upon pressure ;
the motions of the elbow-joint, both of extension and flexion,
are performed with pain ; but the principal diagnostic sign is, Diagnostic
the crepitus produced by the rotatory motion ot the hand and accident,
radius. If the portion of the fractured condyle be large, it is
M M M
450 FRACTURES OF THE ELBOW-JOINT.
drawn a little backwards, and carries the radius with it ; but if
the portion be small, this circumstance does not occur. We have
two excellent |3reparations of this accident in the Museum at
St. Thomas's Hospital, and in neither case has there been any
other than ligamentous union. In one preparation, in which
the external condyle is split obliquely, the bone is somewhat
thickened ; but although this accident had obviously happene4
long before death, no union but that by ligament had been pro-
duced. The second preparation is a specimen of the transverse
fracture of the extremity of the condyle, within the capsular
ligament, in which not the least attempt at ossific union can be
detected. (^See plate.^
It is obvious, therefore, that this principle of ligamentous union
extends to all detached portions within a capsular ligament ; the
vitality of the bone being supported merely by the ligament
within the joint.
This accident usually happens in children, by falls upon the
elbow; at least, in the course of my observation, a very large
proportion of the cases have been in young persons : I have seen
it occur in the adult, but very rarely in advanced age.
Treatment. Tho treatment required is the following : A roller is applied
around the elbow, and above and below the joint. An angular
splint is to be adapted, which should admit the elbow, extend
behind the upper arm, and receive the fore arm (see plate^, so as
to support it ; a roller should then be bound over the whole to
keep it firmly fixed. In the child, this splint may be made of
stiff paste-board, bent to the shape of the elbow; but the best
mode for its application is, to dip it in hot water and apply it wet.
FRACTURES OF THE ELBOW-JOINT. 451
SO that it may exactly adapt itself to the form of the limb ; it thus
becomes the best possible support to the injured arm. Indeed, it
may be here observed, that for children this is the best mode of
making every support of this kind. The splint is to be worn for
three weeks, when passive motion is to be begun ; it must be very
gentle at first, and may be gradually increased as the pain and
inconvenience attending it subside.
The result of the case depends upon the seat of the fracture : Result of
'■ * this injury.
if the bone be broken very obliquely, a steady and long continued
support of the part will occasion it to unite; for in these cases
a considerable portion of the fracture is external to the capsular
ligament ; but if the whole extent of the fracture be within the
ligament, it does not, so far as I have seen, unite by bone, what-
ever be the means employed.
FRACTURE OF THE CORONOID PROCESS OF THE
ULNA.
A gentleman came to London for the opinion of different
surgeons upon the following case :
CASE.
This gentleman had fallen upon his hand whilst in the act of ^ppear-
'-' ^ ances of the
running, and on rising, he found his elbow incapable of being [he'^^ronoid
bent, nor could he entirely straighten it; he applied to his sur- thruiua."
geon in the country, who, upon examination, found that the ulna
M M M 2
452
FRACTURES OF THE ELBOW-JOINT.
projected considerably backwards ; but that so soon as he bent the
arm, it resumed its natural form. He immediately confined the
limb in a splint, and kept it in a sling\ When I saw this gentle-
man in town, several months had elapsed since the accident, yet
the same appearances which the surgeon described when he first
saw the injury, remained; namely, the ulna projected backwards
whilst the arm was extended, but it was without much difficulty
drawn forwards and bent, and the deformity was then rei^ioved.
It was thought, at the consultation which was held about him in
London, that the coronoid process was detached from the ulna,
and that thus, during extension, the ulna slipped back behind the
inner condyle of the humerus.
Dissection.
Treatment.
I had been several years in the habit of mentioning this case at
lecture, when a person was brought to the dissecting-room at
St. Thomas's Hospital who had been the subject of the same acci-
dent, and the joint is preserved in our museum. (See plate.) The
coronoid process, vv^hich had been broken off within the joint, had
united by ligament only, so as to move readily upon the ulna, and
thus alter the sygmoid cavity of the ulna so much as to allow in
extension, that bone to glide backwards upon the condyles of the
humerus.
As to the treatment of this accident, I am doubtful whether any
mode can completely succeed, as the coronoid process, like the
head of the thigh-bone, loses its ossific nourishment, and has
no other than a ligamentous support. Its life is preserved by
the vessels of the refiected portions of the capsular ligament
upon the end of the bone, which do not appear capable of
FRACTURES OF THE ELBOW-JOINT. 453
supporting the least attempt at ossific union ; nor is any change
on the surface of the bone apparent. It will be proper, how-
ever, in this accident, to keep the arm steadily in the bent
position for three weeks after the injury, and thus to make
the ligamentous union as short as possible, by leaving the bone
perfectly at rest.
FRACTURE OF THE OLECRANON.
This process of the ulna is not unfrequently broken off, and
the accident is followed by symptoms which render the injury so JSi^e
evident, that the nature of the case can scarcely be mistaken, oielranon.
Pain is felt at the back of the elbow, and a soft swelling is soon
produced there, through which the surgeon's finger readily sinks
into the joint; the olecranon can be felt in a detached piece,
elevated sometimes to half an inch, and sometimes to two inches,
above the portion of the ulna, from which it has been broken.
This elevated portion of bone moves readily from side to side,
but is with great difficulty drawn downwards ; if the arm be bent,
the separation between the ulna and the olecranon becomes
much greater. The patient has scarcely any power to extend
the limb, and the attempt produces very considerable pain ; but
he bends it with facility, and if the limb be undisturbed, it is
prone to remain in the semiflexed position. For several days
after the injury has been sustained, much swelling of the elbow
is produced ; there is an appearance of ecchymosis to a con-
siderable extent, and an effusion of fluid ensues into the joint
this acci-
dent
454 FRACTURES OF THE ELBOW-JOINT.
in a much larg-er quantity than is natural ; but the extent to which
these symptoms proceed, depends upon the violence which pro-
duced the accident. The rotation of the radius upon the ulna
is still preserved. No crepitus is felt unless the separation of
the bone be extremely slig-ht.
Dissection of this Accident.
The fracture is usually found to have happened through the
Appearances ccutrc of thc olccranon ; and it is most frequently in the transverse
section of dlrcctioH ; but I have seen the bone broken obliquely, so that the
fractured parts presented very thin edges. On that portion of
the olecranon attached to the ulna there are some marks of ossific
inflammation, and some very slight traces of it on the detached
portion. The cancellated structure of the fractured olecranon is
filled by ossific matter, and is sometimes smoothed by occasional
friction. The os humeri and radius undergo no change. Jn the
appearances of one case which I dissected, and of which I have
given a plate, the olecranon is separated two inches from the ulna:
the capsular ligament of the elbow-joint is torn through on each
side of the olecranon ; and the separated portion is united by a
ligamentous band, which is stretched from one broken extremity
of the bone to the other. (See plate.^
The nature of this injury then is as follows : So soon as the
extremity of the bone is broken off", it is, by the action of the
triceps muscle, drawn up from half an inch to two inches from
the ulna, and the extent of its separation depends upon the degree
of laceration of the capsular ligament, and of that portion of the
ligamentous band which proceeds from the side of the coronoid
Mode of
union.
FRACTURES OF THE ELBOW-JOINT. 455
process of the ulna to that of the olecranon. That I might
perfectly understand the nature of this accident, and its means of
reparation, I tried the following experiments on a dog.
Experiments.
The integiiiiients having been drawn laterally and firmly over
the end of the olecranon I made a small incision, and placed a
knife upon the middle of that process, in a transverse direction ;
on striking it with a mallet, the bone was readily cut through ; a
separation directly took place by the action of the triceps muscle ;
adhesive matter was effused ; and when I examined the limb g.
month afterwards, I found the bone united by a strong ligament.
I broke the olecranon in the same manner in several rabbits ;
blood was in these experiments first thrown out, and then adhesive
matter tilled up the space of separation, which subsequently
became ligamentous, and firmer and firmer, as the time was
protracted between the experiment and the examination. As
I found that ligament was formed in each of these experi-
ments, I was anxious to learn whether the olecranon could be
made to unite by bone, if a longitudinal fracture were produced
with but slight obliquity, so that the broken portions might still
remain in contact ; and I found that under these circumstances,
the osseous union readily took place. Therefore, this bone, like
the extremity of the os calcis when it is broken off*, is detached
by the action of muscles, and ligamentous union ensues from union in
want of adaptation ; but a different cause exists where bony union olecranon
•^ depending
fails in fractured bones within ioints in the neck of the thiffh-bone, on^^antof
V o -^ adaptation.
ip the coronoid process of the ulna, and in the extremity of the
456 FRACTURES OF THE ELBOW-JOINT.
external condyle of the os humeri ; in these injuries, the want
of union proceeds from the diminished support which the fractured
parts receive, the little that exists being- derived through the
medium of blood-vessels intended for the nourishment of ligament.
The preparations made from these experiments, may be seen in
the Museum, at St. Thomas's Hospital, i have also seen this
bone in the living person united by an ossific process, when the
fracture has happened very near to the shaft of the ulna.
The ligamentous substance, which generally forms the bond of
union in these cases, is often incomplete ; having* an aperture, and
sometimes several aoertures in it, when it is of considerable
length. The arm is weakened in proportion to the length of the
ligament, for if this be very long, extension of the arm is rendered
difficult from the necessarily diminished power of the triceps
muscle.
Causes of The causcs of this iniury are, first, a fall upon the elbow when
this injury. »/ J 1
the joint is bent ; and secondly, fracture by the action of the
triceps muscle only, when a great and sudden exertion is made
during the flexed position of the arm.
Treatmentof Thc treatment of this accident is as follows; but it is to be
fracture of i' n ^ t r • • t f i
eoiecra- modiiicd accordiHg to the degree of injury. li there be much
swelling and contusion, it is right to apply evaporating lotions
and leeches for two or three days ; and after the inflammation is
reduced, a bandage should be applied ; but in those cases where
but little violence is done to the limb, it should be at once secured
by bandage. The principle of the treatment is to preserve the
power of the limb, by making the separation of the bones as
slight as possible, that their ligamentous union may be shortened;
th
FRACTURES OF THE ELBOW-JOINT. 457
and secondly, to restore the natural motions of the joint. If the
swelling' and inflammation do not prevent it, the surgeon is to
place the arm in a straight position, and to press down the upper
portion of the fractured olecranon until he brings it in contact
with the ulna ; a piece of linen is then laid longitudinally on each
side of the joint, a wetted roller is applied above the elbow, and
another below it, the extremities of the linen are then to be
doubled down over the rollers and tightly tied, so as to cause
an approximation ; thus the bones are brought and held together ;
a splint well padded is to be applied upon the fore part of the arm,
to preserve it in a straight position, and is to be confined to it by
a circular bandage ; the whole is to be frequently wetted with
spirits of wine and water.
This is the only injury of the elbow-joint which requires the
straight position ; those of the condyles and coronoid process
demanding that the limb should be kept bent.
In a month the splint is to be removed, and passive motion is
to be begun ; but if it be attempted earlier, the olecranon will
separate from the shaft of the bone, and the ligament become
lengthened and weakened : all attempts at motion must be made
with the greatest gentleness.
Fracture of the olecranon an inch from the point of the elbow
into the body of the ulna, requires the same treatment as the
common fracture of this portion of bone.
Miss , aged thirty, fell from her horse on her elbow, and
broke the ulna one inch from the point of the olecranon. It was
kept bent three months, and no extension could be produced by
any effort of herself. J forcibly straightened the arm, and kept it so
N N N
458
FRACTURES OF THE ELBOW-JOINT.
by a wooden splint. — Bony union may in this case be readily
produced.
The subjoined plate is intended to shew the band of ligamentous
fibres, which, if it remains untorn, prevents the olecranon from
separating- far from the ulna. In general, however, by bending
the arm, the fracture of the olecranon is easily discovered.
A band of ligamentous fibres crosses from the side of the coro-
noid process to the olecranon ; and upon the radial side of the
ulna, the upper portion of the coronary ligament of the radius
passes from the side of the olecranon towards the neck of the
radius. If the olecranon be broken off, and these ligamentous
fibres be left entire, the olecranon Avill remain still united to the
ulna by means of these ligamentous productions, which I should
not have noticed, but for their influence on fractures of this bone.
a. Os humeri.
b. Radius.
c. Ulna
d. Olecranon.
e. External condyle of the
OS humeri.
f. Internal condyle.
g. Coronary ligament, the
upper part of which
ascends towards the
olecranon.
^ 111
Ligamentous fibres from
the coronoid process
to the olecranon. If
the olecranon be bro-
ken off at the dotted
line, and the upper
part of the coronary
ligament, and these
ligamentous fibres re-
main entire, the bone
moves laterally, but it
separates little from
the ulna.
FRACTURES OF THE ELBOW-JOINT. 459
COMPOUND FRACTURE OF THE OLECRANON.
In compound fractures of this bone, the edges of the skin must
be brought into exact apposition ; lint embued in blood must be
applied on the wound, with adhesive plaster over it, and union by
adhesion must be effected if possible ; but in other respects the
treatment is the same as in simple fracture.
I have seen two cases of this accident, both of which have been
successfully treated.
FRACTURE OF THE NECK OF THE RADIUS.
This fracture I have heard mentioned by surgeons as being of
frequent occurrence, but there must be some mistake in the state-
ment, for it is an accident which I have never seen ; and if
instances ever present themselves (which I do not mean to deny),
they must be very rare.
The injury would be known by fixing the external condyle Diagnosti
of the humerus and rolling the radius, when a crepitus would
be perceived.
If such an accident should occur, the treatment which it will
require will be the same as that which is demanded for fracture
of the external condyle of the os humeri.
N N N 2
marks of thii
accident.
4(jO FRACTURES OF THE ELBOW-JOINT.
COMPOUND FRACTURES AND DISLOCATIONS OF
THE ELBOW-JOINT.
These generally happen through the internal condyles of the os
humeri, and the fracture takes an oblique direction into the joint.
Generally lu tlic Hiost scvcre accidcut of this kind, the constitution is gene-
t'ive. rally able to support the injury, if it be judiciously treated; and
the recital of the following cases will evince the happy result
that may be expected, if union by adhesion be effected in the
treatment.
CASE L
I was called to Guy's Hospital, to see a brewer's servant, who
had a compound fracture of the elbow-joint, caused by his dray
passing over the arm, which had considerably comminuted the
bones. I could pass my finger readily into the joint, and feel
the brachial artery pulsating on its fore part. Considering the
violence done to the part, and the constitution of the patient, who,
like most of those in such employment, drank much porter and
spirits, and ate but little, I at once told him, I feared there
was scarcely any hope of his recovery, unless he consented to
the loss of his limb ; the man, however, determined not to submit
to the operation, although Dr. Hulme, who accompanied me, also
endeavoured to convince him of the necessity of amputation; I
therefore did all in my power to save both his life and his limb.
The bones were easily replaced, and the parts were carefully
brought together. The limb was laid upon a splint, lightly
bandaged, and placed at right angles. The wound united with-
FRACTURES OF THE ELBOW-JOINT. 461
out any untoward circumstance; and the only check that inter-
rupted his progressive recovery, was the formation of an abscess
in the slioulder, which was opened, and immediately healed.
The elbow-joint was not even completely anchylosed, for he
retained sufficient motion in it to allow him to resume his
former occupation.
CASE II.
A gentleman, of the name of Stewart, was thrown from his
chaise, and had a fracture of the condyles of the os humeri, with
a projection of a portion of its inner condyle through the integu-
ments. The edges of the wound were immediately brought
together; and lint, dipped in blood, was laid over them ; evapo-
rating lotions were then applied, and the limb was kept in the
bent position until the fracture was united. He had some use of
the joint afterwards, but its motion was much more limited
than in the former case.
CASE III.
Mr. L — , aged seventy-four, who is nearly my opposite
neighbour in New-street, Spring -gardens, fell down some steps
on the 20th of April, 1818, and shattered his elbow-joint. The
condyles were broken, as well as the olecranon, and the internal
condyle projected through the skin. Mr. Freeman, surgeon in
New-street, was called to him, and he requested me to attend
him. When I visited Mr. L , I found, in addition to the
above-mentioned circumstances, a considerable haemorrhage from
the wound, whilst the comminuted state of the joint allowed
it to be twisted in all directions.
462 FRACTURES OF THE ELBOW-JOINT.
The treatment which we adopted was, to apply lint to the
wound dipped in the blood which flowed from the arm ; recourse
was also had to a many tailed bandage, a pasteboard splint, and
an evaporating lotion. As the parts were in a tranquil state,
the dressing was not disturbed until the 15th of May. Some
matter was discharged from the external wound, but the joint
never manifested any signs of suppuration. The little discharge
that appeared, did not exceed that which a small superficial
wound would produce. The wound was some time in healing,
being prevented by the pressure of the splint, on which the arm
rested. So soon as it was healed, and the bones united, passive
motion was begun ; and although the form of the joint was
irregular, yet a considerable degree of motion was preserved.
This case gratified me exceedingly, the subject of the accident
being universally rejected for his virtues and his talents ; his
constitution was feeble, his age advanced, and he could not have
supported suppuration of the elbow-joint, nor is it probable that
he would have survived the loss of his limb. By the simple
treatment described, all the dangers which threatened him were
averted ; and he has, for several years, survived this very severe
injury. On the contrary, if poultices be applied in these acci-
dents, the adhesive process is prevented, and suppuration pro-
duced, which endangers life, or renders amputation necessary.
CASE IV.
A woman, between fifty and sixty years of age, was admitted
into Guy's Hospital, with a wound of the elbow-joint, and fracture
FRACTURES OF THE ELBOW-JOINT. 463
of both the condyles of the os humeri. A poultice was directed
to be applied, and fomentation ordered twice a day. On the day
following" the accident, she had a considerable degree of fever.
On the third day the upper arm was exceedingly swollen, attended
with an abundant sanious discharge from the wound. On the
fourth day, her strength was greatly reduced, and the wound had
almost ceased to discharge, but the arm was very much swollen.
On the fifth day she died.
In all cases of this accident, the arm should be kept in the bent Treatment
../. II*' 1 1 • ofcompound
position ; for as anchylosis, in a greater or lesser degree, is sure to fractures of
be the consequence, it is attended with much less inconvenience in J°'"''
this position than in any other. If the bones be much commi-
nuted, and the wound large, all the detached portions of bone
should be removed ; but in old people, when much injury is
done, there is often not sufficient strength to support the adhesive
process, and amputation should be recommended. The edges of
the wound should be kept together by placing a piece of lint
dipped in blood over them, supported by adhesive plaster, and a
bandage lightly applied, wetted with spirits of wine and water.
STRUCTURE OF THE WRIST-JOUVT.
Structure of The I'adius, and the three first bones of the carpus, form the
the joint. . /»i ... | !•!• i
articular suriaces or the wrist-joint ; the radius having an oval
cavity at its lower extremity, which receives the rounded surfaces
Bones. ^^ *^® scaphoid, lunar, and cuneiform bones. The articular car-
tilage which covers this surface of the radius is, at its inner edge,
extended beneath the ulna, so as to exclude that bone from the
general cavity of the wrist-joint. This articular cartilage is
hollow, both above and below ; and at its lower surface it rests
upon the os cuneiforme.
Capsular A capsular ligament passes from the edge of the articular
ligament. . /»i t. i c !• • i •! i- i
cavity OT the radius, and irom the interarticular cartilage of the
ulna, to the three first bones of the carpus, surrounding a large
portion of the scaphoid and lunar bones, and but a small surface
of the cuneiform.
^„ . . , The second joint at this part, is that formed between the radius
Ulna joint. J I: '
and the ulna. On the inner side of the lower extremity of the
STRUCTURE OF THE WRIST-JOINT. 465
radius is situated a hollow articulatory surface, which receives an
articular surface on the outer side of the ulna, and both are
covered by an articular cartilag-e. At the lower part of this joint
is placed the interarticular cartilage of the ulna, the outer edge
of which is joined to the articular cartilage of the radius, and
its inner edge is united to the ulna by ligament, which sinks
into a cavity formed at the lower extremity of this bone, between
the styloid process of the ulna and its rounded extremity.
The capsular ligament which unites the ulna to the radius, is
called the sacciform ligament ; it covers the articular surfaces of f a^^g„'|"
the two bones, and is united below to the moveable cartilage of
the ulna. This joint of the wrist is formed for the purpose of
supporting the rotatory motion of the radius upon the ulna, and
of strongly uniting one bone to the other.
The wrist is strengthened on each side by peculiar ligaments ;
one proceeds from the styloid process of the radius, to be fixed to
the outer edge of the scaphoid bone, which is the radio-carpal Radiocarpal
ligament ; and an ulna-carpal ligament extends from the styloid uina carpal.
process of the ulna, to the os cuneiforme, and os orbiculare.
ooo
DISLOCATIONS OF THE WRIST-JOINT.
The dislocations of this joint are of three kinds :
First, dislocation of both bones.
Second, dislocation of the radius only.
Third, dislocation of the ulna.
Mode in The first accident, namely, the dislocation of both bones, is not
which this *
happens. ^^ ^^^T fi*equent occurrence ; but when it does happen, the bones
are thrown either backwards or forwards, according to the direc-
tion in which the force is applied. If the person in falling puts
out his hand to save himself, and falls upon the palm, a dislo-
cation is produced, the radius and ulna are forced forwards upon
the ligamentum carpi annulare, and the carpal bones are thrown
backwards.
Appearance. ijie appcarauccs of this dislocation are these: a considerable
swelling is produced by the radius and ulna, on the fore part of
the wrist, and a similar protuberance upon the back of the wrist
DISLOCATIONS OF THE WRIST-JOINT. 467
by the carpus, with a depression above it ; the hand is bent back,
being" no longer in the line with the fore arm.
In the dislocation of the radius and ulna backwards, the person
falls upon the back of the hand, the radius and ulna are thrown
upon the posterior part of the carpus, and the carpus itself is
forced under the flexor tendons, which pass behind the liga-
mentum carpi annulare ; but in each of these cases two swellings
are produced, one by the radius and ulna, and the other by the
bones of the carpus, according- to the direction in which they are
thrown ; and these become the diag-nostic signs of the accident.
Severe falls upon the palm of the hand will produce sprains of spiaius.
the tendons on the fore part of the wrist, and occasion a very
considerable swelling of the flexor tendons, opposite the wrist-
joint. This accident assumes the appearance of dislocation, but
may always be distinguished from it by the existence of one
swelling only, which does not appear immediately after the injury
is received, but succeeds it gradually. And further, if the
surgeon be called directly after the dislocation has happened,
there is then a great flexibility of the hand, as well as distortion,
and the extremities of the radius and ulna on one side, and of
the carpal bones on the other, are easily detected.
The reduction of this dislocation, in whatever form it may Treatment.
have occurred, is by no means difiicult. The surgeon grasps the
patient's hand with his right hand, supporting the fore arm with
his left, whilst an assistant places his hands around the upper arm,
just above the elbow ; they then pull in different directions, and
the bones become easily replaced. The reduction is in both
cases the same, for the muscles draw the bones towards their
o O o 2
468 DISLOCATIONS OF THE WRIST-JOINT.
natural position as soon as they are separated from the carpus by
extension.
When the hand recovers its natural situation, a roller, wetted
in spirits of wine and water, is to be lightly applied around the
wrist, and the whole is to be supported by splints, placed before
and behind the fore arm, reaching as far as the extremities of the
metacarpal bones, for the more perfect security of the limb.
DISLOCATION OF THE RADIUS AT THE WRIST.
This bone is sometimes separately thrown upon the fore part
Diagnostic L J L r
redden/.''"* of the carpus, and lodged upon the scaphoid bone and the os
trapezium. The outer side of the hand is, in this case, twisted
backwards, and the inner, forwards : the extremity of the radius
can be felt and seen, forming a protuberance on the fore part of
the wrist. The styloid process of the radius is no longer situated
opposite to the os trapezium.
This accident usually happens from a fall when the hand is
arcident. bcHt back ; and I have also known it arise from a fall upon the
hand, by which the condyles of the os humeri were broken
obliquely, and the radius dislocated at the wrist, being thrown
upon the fore part of the scaphoid bone, where it could be
distinctly felt ; this case happened in the lad whom I mentioned
when speaking of fractures of the os humeri ; his hand was
hanging backwards, and he felt great pain upon its being
moved.
I
DISLOCATIONS OF THE WRIST-JOINT. 469
The extension necessary to reduce a dislocation of the radius,
and the treatment which it demands, are the same which are
required for the luxation of both bones ; and there is no difficulty
in the operation, the hand being extended whilst the fore arm is
fixed.
DISLOCATION OF THE ULNA.
As this bone does not form a part of the wrist-joint, but is
received into a capsular ligament of its own, and is separated from
the wrist by a moveable cartilage, it is more frequently dislocated,
separately, than the radius.
When this accident occurs, the sacciform ligament is torn
through, and the bone generally projects backwards, without any
accompanying fracture of the radius. It rises and forms a pro- symptoms.
tuberance at the back of the wrist; and although it is easily
pressed down into its natural position, yet so soon as the pressure
is removed the deformity returns, as the lacerated ligament has
no longer the power to retain it in its place.
The diagnostic marks of the injury are the projection of the Diagnostic
ulna, much above the level of the os cuneiforme, and the altered
position of the styloid process, which is no longer in a line with
the metacarpal bone of the little finger.
The reduction is accomplished by pressure of the bone forwards, Mode of
reduction.
which brings the ulna into its natural articular cavity by the side
of the radius; and to retain it in this situation, splints must be
placed along the fore arm, in a line with the back and palm of
470 DISLOCATIONS OF THE WRIST-JOINT.
the hand ; the splints should be padded throughout ; but upon the
extremity of the uhia a compress of leather should be placed, to
keep it in a line with the radius ; a roller should then be applied
over the splints to confine them with sufficient firmness.
COMPOUND DISLOCATION OF THE WRIST, ULNA
PROJECTED, AND FRACTURE OF THE RADIUS.
June 2lst, ISIS
John Winter fell from a ladder on his hand and knee ; the
hand was bent back, and the ulna protruded at the inner part of
the wrist. Mr. Steel, of Berkhampstead, attended ; the bone was
reduced, a roller was put around the wrist, and the wound healed
very soon by adhesion. In seven weeks he was well, excepting*
that a slight swelling of the tendons remained for a few weeks
lonser.
SIMPLE FRACTURE OF THE RADIUS, AND
DISLOCATION OF THE ULNA.
A frequent The I'adius is frequently broken, and the ulna at the same time
dislocated ; the fracture usually happens one inch above the
articulation. If it occurs in a very oblique direction, so great a
displacement of the radius ensues, that dislocation of the ulna
forwards is also produced.
accident.
DISLOCATIONS OF THE WRIST-JOINT. 471
I have given a plate of this accident, from a preparation of it in
the Museum at St. Thomas's Hospital. (See plate.) The lower Dissection.
end of the radius is seen in its natural situation, articulated with
the carpal bones. An inch above the ligamentum annulare carpi,
the broken extremity of the radius is seen projecting under the
flexor tendons of the wrist, which have been removed to shew
its situation ; the ulna is dislocated forwards, and rests upon
the OS orbiculare.
The signs of this injury are, that the hand is thrown back upon Diagnostic
marksofthis
the fore arm, so as, at first sight, to exhibit the appearance of a accident.
dislocation of the hand backwards ; and a projection of the ulna is
felt under the tendon of the flexor carpi ulnaris muscle, just above
the OS orbiculare ; and thirdly, the fractured extremity of the
radius is easily detected, under the flexor tendons of the hand.
I have seen this accident frequently, and at first did not exactly
understand the nature of the injury; indeed, dissection alone,
taught me its real character.
A very powerful extension is required to brinff the broken ends Mode ot
. . reduction
of the radius into apposition, and great difficulty exists in con- ^
fining them when this is effected. The hand is to be extended by
the surgeon, and the fore and upper arm are to be drawn back by
an assistant ; then a cushion is to be placed upon the inner part of
the wrist, and another to the back of the hand, firmly bound down
by a roller, for the purpose of keeping the ulna and broken end of
the radius in situ ; a splint, well padded, is then to be applied to
the back part and inner side of the fore arm, which is to extend to
the extremities of the metacarpal bones ; these splints are to be
confined by a roller, reaching from the upper part of the fore arm
its diffi-
culties.
472
Symptoms
of this
accident.-
Treatment.
DISLOCATIONS OF THE WRIST-JOINT.
to the wrist, and no further. The arm should be then placed in a
sling : this position is to be preserved for three weeks in young
persons, and for four or five in the aged, before passive motion be
attempted. The recovery in these cases is slow, and six months
will sometimes elapse before motion of the fingers is completely
restored. (See plate.^
FRACTURE OF THE LOWER END OF THE RADIUS
WITHOUT DISLOCATION OF THE ULNA.
This fracture generally happens about an inch above the styloid
process. The cure is difficult, the lower extremity of the broken
bone being drawn by the action of the pronator quadratus amongst
the flexor tendons, where it may be distinctly felt; in this situation
it interferes very considerably with the motions of the fingers, by
confining the action of the flexor profundus perforans. Mr. Cline,
in his lectures on this subject, used, nearly in these terms, to
recommend the following treatment : " When a fracture of the
radius happens just above the wrist-joint, you must be very careful
in your treatment of it, to prevent the injury from leading to the
permanent loss of the use of the fingers ; for so soon as the injury
has happened, the pronator quadratus muscle draws the fractured
end of the bone obliquely across the fore arm, amidst the flexor
tendons ; your object, therefore, in the treatment of this accident
is, to prevent the action of the pronator from producing that
effect ; and the mode of treatment which you are to adopt is, to
DISLOCATIONS OF THE WRIST-JOINT. 473
make the hand by its weight oppose the action of that muscle.
For this purpose, when the bone has been placed in its right
position, by drawing the hand in a line with the fore arm, apply a
roller around the fore arm to the wrist ; then a splint upon the
fore and back part of the arm to reach to the palm and back of
the hand, so as to preserve it in a half supine position ; and
confine the splints by means of a roller, which should reach only
to the wrist. The arm is then to be placed in a sling, which is
also to support it no further than to the wrist. Thus, the hand
being allowed to hang between the ends of the splints, draws the
end of the radius, so as to maintain a constant extension upon it,
opposing the action of the pronator quadratus muscle, and keeping
the broken end of the bone constantly in its place."
COMPOUND DISLOCATION OF THE ULNA, WITH
FRACTURE OF THE RADIUS.
This is a very serious accident when the radius is much com- ^,
.' Often a very
minuted (see plate^, but recovery proceeds very well, when the atm."^ ''*^'^"
radius is broken without being shattered. I saw a case of this
injury in Hertfordshire, in which the man met with the accident
by falling upon the back of his hand, and the ulna protruded an
inch and a half through the integuments; the bone was imme-
diately reduced and bandaged ; the wound healed by the adhesive
process, and the man recovered the perfect use of his limb.
P P P
474 DISLOCATIONS OF THE WRIST-JOINT.
CASE I.
Susannah Griffith, a woman from Rotherhithe Poorhouse,
aged seventy-two, was admitted into Guy's Hospital, on the
10th of April, 1822. Whilst walking on the pavement, her
foot had accidentally slipped, and she fell with her right hand
under her, in such a manner, that the palmar surface was
forcibly bent against the inner side of the fore arm ; the
carpal extremity of the ulna was, consequently, thrown violently
outwards through the integuments, and the lower end of the
radius was obliquely fractured.
The parts were reduced, and the edges of the wound brought
as closely into contact as the lacerated condition of it would
admit ; a pledget of lint, dipped in blood, was applied to the
part, and a bandage over it.
On the third day the arm became tumefied and inflamed, and
poultices were applied. By the 21st of May, the fracture of the
radius had united, and the patient recovered the use of the thumb
and two first fingers ; the whole of the articular cartilage had
come off in the form of black sloughs, intermixed with spiculse of
the subjacent bone, and the granulations were so prominent, as to
lead to the application of adhesive straps ; the healing process,
however, was greatly retarded by a frequent displacement of the
extremity of the ulna, owing to the constitutional irritability of
the patient, and to the oedematous state of the arm, which did
not allow the bandages to be applied with the tightness requisite
for its due confinement.
On the 1 8th of June, the wound was nearly healed ; but still
DISLOCATIONS OF THE WRIST-JOINT. 475
a small portion of the end of the ulna will exfoliate, and she
applies the lotion acidi nitrici, to hasten its exfoliation.
Pkploe Cartwright,
August I9th, 1822. Dresser, Guys Hospital.
CASE II.
A man was admitted into St. Thomas's Hospital, under the care
of Mr. Chandler. I now forget in what manner the accident had
happened, but the ulna projected through the integuments at the
back of the carpus ; and a compound fracture of the radius, with
great comminution of the bone, was produced. The ulna was at
first replaced, but immediately resumed its dislocated position on
the back of the wrist, although it did not again protrude through
the skin. The hand and fore arm were placed in a poultice, and
were ordered to be fomented twice a day. A copious suppuration
ensued, attended with violent constitutional irritation ; and Mr.
Chandler, in order to save the patient's life, after a lapse of five
weeks, amputated the limb.
On dissection, I found the ulna dislocated backwards, and its Dissection.
extremity just drawn within the opening of the integuments,
through which it had protruded. The radius was broken into
several pieces, some of which being loose, were necessarily a
great source of irritation ; the tendons and muscles were some
of them lacerated, as the extensor carpi radialis longior, and the
extensors of the thumb.
In a similar case it would be proper, when loose pieces of bone Treatment.
can be felt at the extremity of the radius, that the wound should
be enlarged for their removal ; and instead of fomentations and
P P P 2
476 DISLOCATIONS OF THE WRIST-JOINT.
poultices, a quantity of lint, dipped in the patient's blood, should
be applied round the wrist, lightly bound with a roller. The arm
should be supported upon a splint, so as to be kept perfectly
free from motion ; evaporating lotions should be applied ; and
the limb should not be disturbed, unless the patient has symptoms
of a suppurative process, when a small opening should be made
in the bandage to allow of the escape of pus, but still the band-
ages should be suffered to remain. The patient should be bled
from the arm if the inflammation and constitutional irritation be
considerable, and under these circumstances, leeches should be .
occasionally applied. The bowels should be kept gently open, but
all active purging avoided.
DISLOCATIONS of the CARPAL-BONES.
The eight bones of the carpus are joined to each other by short
Hgaments, which pass from bone to bone, allowing but a very
slight degree of motion of one bone upon another ; but, beside
this mode of articulation, there is a transverse joint between the carpai joint.
first and second row of carpal bones, forming a complete ball and
socket. The ball is produced by the rounded extremities of the
OS magnum, and os cuneiforme : the cup, by the scaphoid, lunar,
and cuneiform bones. A ligament passes from one row of bones
to the other, including this articulation.
The dislocation of a carpal-bone is but of rare occurrence ; the
following is an example of it :
CASE.
Mary Nichols, aged sixty, slipped down, and, trying to save
herself, fell upon the back of her hand and fractured the radius
obliquely outAvards, through the lower articulating surface. The
fractured portion, with the os scaphoides, was thrown backwards
478 DISLOCATIONS OF THE CARPAL7BONES.
upon the carpus. The wrist was slightly bent, and there was an
evident projection at the back of the carpus. The fingers could
be completely extended, but only semiflexed. A crepitus might
be distinctly felt, either by moving the hand, or the styloid process
of the radius backwards or forwards. By slight extension, and
steady pressure upon the displaced part, the fracture was easily
reduced. There was much extravasation and pain ; six leeches
were applied, afterwards evaporating lotions, and two long splints;
and as soon as the swelling had in some measure subsided, strips
of soap plaster. At the end of six weeks the fracture was firmly
united, but the motions of the wrist are still imperfect, and she
cannot grasp any thing'.
F. R. Elkington,
August \Zth, 1822. Dresser, Guy's Hospital.
Ganglia are sooietimes mistaken for this accident ; but in such
cases a smart bloAv with a book will disperse the swelling, and
dispel the cloud of doubt which enveloped the mind of the
surgeon.
Relaxation The OS maguum and the cunneiform bone, from relaxation of
joint. their ligaments, are sometimes thrown somewhat out of their
natural situation, so that when the hand is bent, they form protu-
berances at the back of the wrist. This state is productive of so
great a degree of weakness, as to render the hand useless unless
the wrist be supported. I was consulted by a young lady, a
patient of Mr. Gumming, of Chelsea, who had such a projection of
the OS magnum, that she was, in consequence, obliged to give up
her music and other accomplishments, on account of the attendant
DISLOCATIONS OF THE CARPAL-BONES. 479
weakness; for when she wished to use her hand, she was compelled
to Avear two short splints, which were adjusted to the wrist, and
bound upon the back and fore part of the hand, and fore arm.
Another lady, who had a weakened state of limb, arising from a
similar cause, wore for the purpose of giving it strength, a strong
bracelet of steel chain, clasped very tightly around the wrist. But
the supports generally directed to be worn in these cases are
straps of adhesive plaster, and a bandage over the wrist to confine
and strengthen it. The affusion of cold water upon the hand
from a considerable height is also employed, and the part is after-
wards rubbed with a coarse towel, to give vigour to the circulation,
and strength to the joints.
COMPOUND DISLOCATION OF THE CARPAL-BONES.
These accidents are of frequent occurrence, and they are
generally caused by guns bursting in the hand ; portions of the
instrument being forced through the carpus, and between the
metacarpal-bones.
In these cases a carpal-bone may be removed by dissection, and
the patient may recover ; not only saving his hand, but, in a con- Recovery.
siderable degree, preserving its motions ; of which the following
is a good example :
CASE.
Richard Mitchell, aged twenty-two, was admitted into Guy's
Hospital, under Mr. Forster, on the 17th of October, 1822, for an
480 DISLOCATIONS OF THE CARPAL-BONES.
extensive wound in the wrist-joint, inflicted by what is called a
wool-comber's devil. On examination it was found that the wound
extended through two thirds of the circumference of the joint,
and was attended with a great deal of contusion ; the scaphoid
bone projected at the back part, being attached only on the side
towards the joint ; in consequence of this, the joints into which
it enters were laid open ; the extensor tendons of the thumb, and
of the middle and fore fingers, were torn through; the radial artery
was also torn, but did not afford any considerable haemorrhage.
The scaphoid bone was removed with a scalpel; the edges of the
wound were brought together by sutures, and lint dipped in blood
was applied to it and confined by adhesive straps ; the fore arm
and hand were laid on a splint, so as to keep the joint perfectly at
rest ; the patient was bled to twelve ounces, and an evaporating
lotion ordered. In two or three davs the dressings were removed,
in consequence of the pain, when a good deal of surrounding
inflammation was found, and in one spot a slough; the sutures
were removed, and a poultice ordered ; two or three days after
this, abscesses formed along the thecse of the tendons which were
opened. The slough quickly separated, and the inflammation
subsided, as the suppurative process became established. In two
or three weeks, the wound was so well filled, as to allow the
application of adhesive straps, under which treatment it gradually
healed. The only constitutional symptoms which occurred during
the progress of the case were those of common irritative fever,
which were relieved by the exhibition of antimony, with opium
and the liq. aumion. acet. with the tinct. opii. and the use of mild
cathartics ; and a pulmonic affection, which threatened phthisis.
DISLOCATIONS OF THE CARPAL-BONES. 481
was relieved by the use of leeches and diaphoretics, which, how-
ever, considerably retarded his recovery.
Whilst his wound was in the progress of healing, passive
motion was early and regularly resorted to ; and after "it had
healed, friction, with the soap liniment ; but he had only a limited
power of moving- his fingers when he left the hospital.
The only intelligence I can now gain of him is, that he has
lately gone to work, under the hope that the constant habit of
grasping bodies (which indeed I strenuously recommended to him
previously), will restore the motion of his fingers.
Charles Fagg,
Aug. I2th, 1822. Dresser to Mr, Forster,
Guys Hospital.
When only one or two of the carpal-bones are displaced by
guns bursting in the hand, they may be dissected away; but if
more considerable injury be done, amputation will be necessary.
Q Q Q
DISLOCATIONS of the METACARPAL-
BONES.
These bones are so firmly articulated with the bones of the
carpus, that I have never seen them dislocated but by the bursting
of guns, or by the passage of heavy laden carriages over the
hand; and in each of these cases there is generally so much
Amputation iujury produccd as to render amputation necessary. In the
often neces-
sary, former of these accidents, a bone, and sometimes two, are capable
of being removed ; and if it be necessary to amputate the middle
and ring finger, the fore and little finger may be so nicely
brought together, and secured in such exact adhesion, as to
produce little deformity.
CASE I.
I was called by Mr. Hood, surgeon at Vauxhall, to a Mr.
Waddle, of Bow-lane, Cheapside, who, whilst shooting, had his
gun burst, and his hand lacerated by a portion of the barrel
passing through its centre ; the metacarpal-bones of the middle
and ring fingers were fractured, and also much comminuted by
i
DISLOCATIONS OF THE METACARPAL-BONES. 483
the violence of the injury, but the integuments were only la-
cerated, and not completely removed. I dissected out the two
fingers, with the metacarpal-bones which supported them, and
brought the edges of the skin together by suture, approximating
the fore and little finger, and applying a roller, so as to bind them
together ; the parts united perfectly, and the maimed hand was
afterwards extremely useful to him ; the case, indeed, is highly
worthy inspection.
CASE n.
A boy of twelve years of age was brought into Guy's Hospital,
who, by the bursting of a gun, had his thumb and all the fingers,
excepting the fore finger, blown to pieces ; the whole hand was
exceedingly shattered, and the metacarpal-bones were separated
from the carpus. Upon examination of the hand, I found that
the tendon of the fore finger was uninjured, so that its use
remained perfect ; and as the integument could be still saved, so
as to cover its metacarpal-bone, I dissected out the trapezium
(the thumb had been entirely carried away by the concussion),
and the metacarpal-bones of all the fingers, excepting that of
the fore finger, which was afterwards of the greatest use to him.
I kept him for some time at the hospital to shew to the students
the restorative powers of nature, and the utility of this finger,
saved out of the wreck of his hand ; he used it as a hook with
the greatest facility.
Q Q Q 2
484 DISLOCATIONS OF THE METACARPAL-BONES.
FRACTURE OF THE HEAD OF THE METACARPAL-
BONE.
Fracture.
The extremity of the metacarpal-boiie towards the fingers,
which is called its head, is sometimes broken off, and it gives the
appearance of dislocation of the finger, as the head of the bone
sinks towards the palm of the hand. In the treatment of this
case, a large ball is to be placed in the hand, grasped by it, and
bound over it by a roller ; and thus the depressed extremity of
the bone is raised to its natural situation.
DISLOCATIONS OF THE FINGERS
AND TOES.
The phalanges of the fingers and of the toes are united by gj^^^.^^,^
capsular ligaments to the metacarpal and metatarsal-bones, and
to each other ; and their union is further strengthened by lateral
ligaments, proceeding from the side of one phalanx to the other.
Posteriorly, they are defended by the tendon of the extensor
muscle of the fingers; and anteriorly, by the thecse and flexor
tendons. Dislocation of the phalanges, therefore, is but rare;
but when this accident does occur, it more frequently happens
between the first and second phalanges, than between the second
and third.
In plate xxviii. this dislocation will be seen ; the second
phalanx being thrown forwards towards the thecae, and the first,
backwards. I could not learn if the ligaments had been torn,
as the dislocation had existed for a length of time, and the
ligament, if it had ever been lacerated, was then united : the
extensor tendon was very much stretched over the end of the
first phalanx.
486 DISLOCATIONS OF THE FINGERS AND TOES.
Diagnostic This accidciit may be readily distinguished by the projection of
marks of
thisacci- the first phalanx backwards, while the head of the second may be,
although less distinctly, felt under the thecse.
Reduction. The rcductiou may be effected by making extension Avith a
slight inclination forwards to relax the flexor muscles. If the bone
has not been dislocated many hours, it is easily reduced; but if
neglected at first, this can only be accomplished by a long-
continued extension very steadily applied. I have seen too much
mischief arise from injury to the tendons and ligaments of these
joints, ever to recommend the division of them (which some have
advised) to facilitate reduction, when extension will not succeed.
The observations which I have made respecting the dislocation
of the lingers, also apply to the toes ; of which, however, the
dislocations are more difficult to reduce, from their greater short-
ness, and the less pliability of the joints.
Contraction
of tendon.
DISLOCATION FROM CONTRACTION OF THE
TENDON.
A toe or finger is sometimes gradually thrown out of its natural
direction, by a contraction of the flexor tendon and thecse ; and
the first and second phalanges are, consequently, drawn up and
projected against the shoe, so as to prevent the patient from being-
able to take his usual exercise.
I have frequently seen young ladies subject to this incon-
venience in the toe, and attribute it to the tightness of their
DISLOCATIONS OF THE FINGERS AND TOES. 487
shoes : it appears an extremely harsh measure on the part of Amputation
' '^ '' *■ required.
the sjirgeon to amputate a toe under such circumstances, yet it is
sometimes absolutely necessary, as the contraction deprives the
person of exercise, and of many of the enjoyments of life. In the
first person whom I saw with this state of the toe I refused to
amputate, fearful of tetanus being produced by the operation ; but
the lady went to another surgeon, who complied with her request,
and she did very well. In consequence of the perfect recovery of
this lady, and the comfort which she derived from the loss of the
annoyance, I was induced, at the request of Mr. Toulmin, of
Hackney, to remove from Miss T , a patient of his, one of her
toes, which was constantly irritated by the pressure of her shoe in
walking, and prevented her from taking the exercise necessary
to the preservation of her health ; she did very well, perfectly
recovering the use of her foot.
The fingers are sometimes contracted in a similar manner by a
chronic inflammation of the thecee, and aponeurosis of the palm of
the hand, from excessive action of the hand, in the use of the
hammer, the oar, ploughing, &c. &c. When the thecee are con-
tracted, nothing should be attempted for the patient's relief, as no
operation or other means will succeed ; but when the aponeurosis
is the cause of the contraction, and the contracted band is narrow,
it may be with advantage divided by a pointed bistoury, intro- Division of
aponeurosis.
duced through a very small wound in the integument. The
finger is then extended, and a splint is applied to preserve it in
the straight position.
Last September twelvemonth, my nephew, Mr. Bransby Cooper,
who was transacting my business during my absence from town,
488 DISLOCATIONS OF THE FINGERS AND TOES.
performed this operation for a Lincolnshire farmer, who, by this
circumstance, had been prevented following" his avocations ; and
he pei'fectly recovered the use of his foot.
DISLOCATION OF THE THUMB.
These accidents are very difficult to reduce, on account of the
numerous strong muscles which are inserted into the part.
The thumb consists of three bones : its metacarpal-bone, and
two phalanges. The metacarpal-bone of the thumb is articulated
with the OS trapezium by means of a double pulley ; that of the
trapezium directing the thumb towards the palm of the hand, and
that of the metacarpal-bone directing it laterally. The meta-
carpal-bone is connected with the trapezium by a capsular
ligament, and a very strong ligament joins the first phalanx to
the palmar part of the trapezium, at its lower extremity. The
metacarpal-bone forms a rounded projecting articulatory surface,
upon which the hollow of the first phalanx rests, both being
surrounded by a capsular ligament, and strengthened by two
strong lateral ligaments. There are eight muscles inserted into
the thumb ; two into the metacarpal-bone, as the extensor and
flexor ossis metacarpi ; two into the first phalanx, the flexor
brevis pollicis, and the extensor primi internodiij the abductor
and adductor pollicis are also inserted into the first phalanx,
through the medium of the sesamoid bones ; the extensor secundi
internodii and flexor longus pollicis are inserted into the second
DISLOCATIONS OF THE FINGERS AND TOES. 489
phalanx. These muscles necessarily offer great resistance to the
reduction of dislocations, and therefore those of the thumb are
amongst the most difficult to reduce, if any considerable time be
allowed to elapse after the accident has occurred, before the
attempt at reduction be made.
DISLOCATION OF THE METACARPAL-BONE FROM
THE OS TRAPEZIUM.
In the cases which I have seen of this accident, the metacarpal- symptoms.
bone has been thrown inwards, between the trapezium, and the
root of the metacarpal-bone supporting the fore finger ; it forms
a protuberance towards the palm of the hand ; the thumb is bent
backwards, and cannot be brought towards the little finger. Con-
siderable pain, with swelling, is produced by this accident.
For the facility of reduction, as the flexor muscles are much Mode
adopted for
stronger than the extensors, it is best to incline the thumb towards reduction.
the palm of the hand during extension, and thus the flexors
become relaxed, and their resistance diminished. The extension
must be steadily, and for a considerable time, supported, as no
sudden violence will eff'ect the reduction. If the bone cannot be
reduced by simple extension, it is best to leave the case to the
degree of recovery which nature will in time produce, rather than
divide the muscles, or run any risk of injuring the nerves and
blood-vessels.
This bone is sometimes dislocated by the bursting of a gun,
R R R
490 DISLOCATIONS OF THE FINGERS AND TOES.
Compound
luxation.
which produces compound luxation ; it can in these cases, usually,
be with ease returned to its natural situation ; the integuments
being brought and confined over it by suture, a poultice is applied;
and under common circumstances, where the degree of bruise has
not been very considerable, a cure is perfected. Sometimes, how-
ever, the metacarpal-bone becomes so much detached from the
trapezium, and the muscles are so severely torn, that it is neces-
sary to remove the thumb, in which case it is best to saw off
the articular surface of the trapezium. Such a case happened
lately to a servant of Mr. Grover, of Hemel Hempstead: the
metacarpal bone of the thumb was dislocated, and the muscles
were so much lacerated, that it became necessary to remove the
thumb at the os trapezium ; but the articular surface of the tra-
pezium projected so far that the integuments could not be
brought over it, I therefore directed this surface to be sawn oflT,
through the os trapezium ; and a poultice being applied, the man
recovered by the granulating process.
Dear Sir, Brentford, April 6th, 1820.
I some time since promised to send you an account of a
compound dislocation of the thumb, which came under my care
during the last year, but really I have been in such a whirl of
engagements, that I have not until this evening had leisure to
look at my notes of the case.
CASE.
Master Arthur Trimmer, aged thirteen years, on the 2nd of
DISLOCATIONS OF THE FINGERS AND TOES. 491
February, 1819, whilst a wild-fire was gTadiially consuming, was
in the act of adding, from a copper flask, dry powder, of which it
contained about half a pound, when explosion took place, and the
flask bursting in his hand, caused severe laceration of the palm,
and a compound dislocation of the thumb. The whole mass of
muscle connecting the thumb with the hand was completely torn
through ; and observing the thumb lying upon the carpus, dis-
located from its articulation with the trapezium, I was about to
have removed it with a scalpel, when 1 saw the tendon of the
flexor longus poUicis glisten in its sheath, uninjured, as well as
the tendon of the extensor longus ; I therefore put the parts in
something like a natural position, and took ten minutes to reflect
upon the best mode of proceeding. The haemorrhage was great
at the moment, but the wound being contused and lacerated, it
ceased on slight pressure.
Considering the thumb of the right hand to be a very important
organ, I resolved, if possible, that it should be preserved, assuring
the friends of the young gentleman, who were under great appre-
hension lest tetanus should ensue, that the probability of trismus
supervening, would not be increased by the attempt to save the
thumb.
That intelligent surgeon, Mr. Brodie, having been also sent for
at the time of the accident, arrived in about three hours, when
being of opinion with myself that there was a chance that the limb
might be saved, I brought the parts together with three ligatures,
two towards the palm, and one on the posterior part of the hand,
put on adhesive straps, allowing sufficient room for extension, and
to the hand and fore arm applied an evaporating lotion. Gave
R R R 2
492 DISLOCATIONS OF THE FINGERS AND TOES.
him at bed-time a pill containing three grains of calomel and one
of opium, and in the morning a cathartic mixture.
February 3rd. Had a restless night, but the part not very
painful.
February 4th. His pulse running 120 and hard, I took away
about eight ounces of blood, and ordered him the effervescing
mixture, paying attention to the state of the bowels. Continued
the antiphlogistic plan.
February 7th. Removed the dressings and ligatures, and had
the pleasure to find that considerable adhesion had taken place ;
that no tetanic symptoms made their appearance, and that every
day he suffered less from constitutional irritation.
February 9th. Again removed the dressings, wound looking
healthy, and suppuration not considerable ; I therefore continued
to dress with adhesive plaster, small quantities of lint, and over
that a bandage about an inch wide and two yards long, by means
of which sufficiently equable pressure could be made to promote
the inosculation of granulating surfaces, as well as to produce a
tolerably even external state of the parts during the advance of
the adhesive process.
From this time it was dressed every second day, and on the
sixteenth I began to give it passive motion, at first by simply
bending the first phalanx of the thumb, so as to break down any
adhesions that might have taken place between the tendons and
their thecae. By the twenty-third I gave trifling motion to the
second phalanx, and towards the end of the month the wound was
healed. Through the month of March I gradually increased the
motion, and on the 1st of April, my little patient left Brentford on
DISLOCATIONS OF THE FINGERS AND TOES. 493
a visit to the Isle of Wight, with injunctions to give dally motion
to the joint ; and I am happy to add, he now makes use of it in
writing as well as ever, and finds the thumb perfectly useful for
all the ordinary purposes of life.
I am, dear Sir,
Most truly your's,
George Cooper.
DISLOCATION OF THE FIRST PHALANX.
This accident may be either simple or compound. I shall first Diagnostic
describe the simple dislocation. In this accident the first phalanx simple dislo-
cation of the
is thrown back upon the metacarpal-bone, and the lower extremity firstphaianx.
of the latter projects very much inward towards the palm of the
hand, and the extremity of the phalanx projects backwards. The
motion of that joint is lost, but that of the thumb, through the
medium of the metacarpal-bone and trapezium, remains free ; so
that, as an opponent to the fingers, its power of action continues ;
but with respect to flexion and extension, which are performed
between the metacarpal-bone and the first phalanx, they are
destroyed by the dislocation.
The extension is to be made by bending the thumb towards the Mode of
palm of the hand, to relax the flexor muscles as much as possible ;
and the following is the mode of applying the extending force,
which may be considered as the general mode to be adopted in
dislocations of the toes, thumb, and fingers. The hand is to be
49J^ DISLOCATIONS OF THE FINGERS AND TOES.
first steeped in warm water for a considerable time, to relax the
parts as much as is possible ; then a piece of thin wetted leather,
wash-leather for instance, is to be put around the first phalanx,
and as closely adapted to the thumb as possible ; a portion of tape
about two yards in length is then to be applied upon the surface
of the leather, in the knot which is called by sailors the clove
hitch (see piatej, for this becomes tighter as the extension
proceeds. An assistant places his middle and fore finger between
the thumb and fore finger of the patient, and makes the counter
extension, whilst the surgeon, assisted by others, draws the first
phalanx from the metacarpal-bone, directing it a little inward
towards the palm of the hand.
The extension should be supported for a considerable length of
time, and if success does not attend the surgeon's efforts, it is
right to adopt the following plan : The leather and sailors' knot
are to be applied as before directed, and a strong worsted tape is
to be carried between the metacarpal-bone of the thumb and the
fore finger ; the arm is then to be bent around a bed-post, and
the worsted tape fixed to it ; a pulley is then to be hooked to the
tape which surrounds the first phalanx, and extension is to be
made : this mode is almost sure to succeed. If, however, under
the steadiest, best directed, and most persevering attention, the
bone be not reduced, a disappointment which will sometimes
happen in dislocations which have been neglected, then the
surgeon's efforts must cease ; no operation for the division of
parts should be made, as the patient will have a very useful
thumb after a time, even without reduction.
In compound dislocations of the first phalanx of the thumb, if
DISLOCATIONS OF THE FINGERS AND TOES. 495
Treatment
of compound
dislocation
of the
there be much difficulty in its reduction, and the wound be large,
it is best to saw off the extremity of the bone, rather than to d!
bruise the parts by long- continued extension : they are to be thumb.
healed by adhesion ; and if passive motion be begun early, a
joint will soon be formed, and a very useful member remain. In
this case lint, dipped in blood, is to be applied to the wound ; a
roller must be bound round, and the part kept cool by evaporating
lotions for several days, until the wound be healed.
I very recently saw the following case of compound dislocation
of this bone.
CASE.
A gentleman came to my house, whose first phalanx had been
thrown upon the back of the metacarpal-bone of the thumb by the
bursting of a gun. The flexor muscles, and the abductor, were
much lacerated just below the os trapezium ; the extensors were
not injured. I applied the tape to the first phalanx, and ex-
tending, easily reduced it; I then brought the edges of the
integuments together by suture, and directed a poultice to be
applied, on account of the great contusion of the parts ; and the
recovery was very complete.
DISLOCATION OF THE SECOND PHALANX.
If this be a simple dislocation the best mode of reducing it is, simple.
that the surgeon should grasp the back of the first phalanx with
his fingers, apply his thumb upon the fore part of the dislocated
496
DISLOCATIONS OF THE FINGERS AND TOES.
phalanx, and then bend it upon the first as much as he possibly I
can.
Compound. In coinpound dislocations of this joint (of which I have given
a plate), it is best to saw off the extremity of the second phalanx,
taking care not to injure the tendon which is torn through ; for
when the bone is removed, the ends of the tendon may be readily
approximated, and adapted to each other. The extremity of the
tendon should be smoothed by a knife, and the part be then
bound up in lint, dipped in blood, confined by a roller ; and it
should be kept quiet for a fortnight or three weeks, when passive
motion may be begun.
DISLOCATION OF THE RIBS.
Authors describe different species of dislocations of the ribs ;
their heads are said to be thrown from their articulation with the
vertebrae forwards upon the spine ; if this accident ever does
occur, it is certainly extremely rare, and must be very difficult of
detection.
A person, by falling on his back upon some pointed body, may, Heads of
however, receive a blow upon his ribs, by which they may be
driven from their articulations.
Such an injury would produce the usual symptoms of fracture symptoms,
of these bones ; their motions would be painful, and respiration
necessarily difficult.
The treatment which would be required, would also be the Treatment.
same as that which is pursued in fracture of the ribs, viz., the
abstraction of blood, and the application of a circular bandage ;
the former to prevent inflammation of the pleura and lungs ;
the latter to lessen the motion of the ribs. Any attempt made
to effect their reduction would be entirely fruitless.
s s s
498
DISLOCATION OF THE RIBS.
Cartilages. 'pjjg cai'tilages connecting" the ribs with the sternum frequently
appear to have been dislocated from the extremities of the ribs,
and sometimes from the sternum. Mothers have several times
brought their children to me, saying, "My child has sometime
since had a fall, and see how the form of its breast is altered."
The sixth, seventh, and eighth cartilages of the ribs are most
frequently the subjects of this alteration of form ; and when the
ribs are carefully examined, it is found that their natural arch is
diminished, their sides flattened, and, consequently, the extremities
of the ribs, with their cartilages, thrust forward ; the appearance
which is thus produced is the result of constitutional weakness,
and not of the accident to which it is attributed.
The termination of the cartilages at the sternum sometimes
projects from a similar cause, giving rise to the same false impres-
sion upon the minds of the parents, that the circumstance must
have arisen from accident, and not from disease. Sometimes,
Sciw^^ however, but very rarely, a cartilage is torn from the extremity of
separated. ^^^ j.jj^^ ^^^ projccts ovcr its surfacc ; when this happens, a similar
Treatment, treatment is required as in fracture of the ribs. The patient is to
be directed to make a deep inspiration, and then the projecting
cartilage is to be pressed into its natural situation ; a long piece of
wetted paste-board should be placed in the course of three of the
ribs and their cartilages, the injured rib being in the centre ; this
dries upon the chest, takes the exact form of the parts, prevents
motion, and affords the same support as a splint upon a fractured
limb. A flannel roller is to be applied over this splint, and a
system of depletion pursued, to prevent inflammation of the
thoracic viscera.
INJURIES OF THE SPINE.
It has been generally stated by surgeons that dislocations of „. .
^ •/ J n Dislocations
the spinal column frequently occur ; but if luxation of the spine "^^^ '^^'*'
ever does happen, it is extremely rare; as in the numerous
instances which I have seen of violence done to the spine, I have
never witnessed a separation of one vertebra from another through
the intervertebral substance, without fracture of the articular
processes ; or, if those processes remain unbroken, without a
fracture through the bodies of the vertebrae. Still I would not
be understood to deny the possibility of dislocation of the cervical
vertebrae, as their articulatory processes are placed more obliquely
than those of the other vertebrae. I must, however, observe, that
from the vicinity of our hospitals to the river, sailors are often
brought into them with injuries of the spine, by falls from the
yard-arm to the deck; and as there is almost always an oppor-
tunity of inspection in these cases, a dislocation must be extremely
rare, since I have never met with a single instance of it, those
injuries having all proved to be fractures with displacement.
S S S 2
500
INJURIES OF THE SPINE.
I am well aware that respectable surgeons have described dislo-
cations as occurring- in the cervical vertebrae, but I wish to state
my own experience, with no further reference to that of others.
Structure.
Bones.
Interverte-
bral sub-
stance.
Anterior
spinal liga-
ment.
Posterior
spinal.
The following short account of the structure of the spine, is
given merely to revive the ideas which may have faded from the
memory.
The spinal column is composed of twenty-four vertebrae, which
are divided into three classes, namely: the cervical, dorsal, and
the lumbar; they are very strongly connected by four articular
processes, and are firmly joined by an elastic substance, which pro-
ceeds from the broad surface of the body of one vertebra to that of
the other. The spinous processes of many of the vertebrae, and
particularly those nearest to the centre of the column, are locked
together, one being admitted into a depression of the other.
The bodies of the vertebrae are united by a ligamento cartilagi-
nous substance, extremely elastic, and composed of concentric
lamellae, connected by oblique fibres, which decussate each other,
but in the centre become mucous, so as to form a pivot, which
supports the central line of the vertebrae; whilst the elasticity and
compressibility of the outer edge of this uniting medium, allows
the vertebrae to move upon this centre in all directions. The
column is also further connected by an anterior spinal ligament,
which proceeds from the second vertebra of the neck to the
sacrum, and is united to all the bodies of the vertebrae excepting
the first. There is also a posterior spinal ligament, situated
within the canal of the spinal column, and proceeding from the
second vertebra ; but it is also intermixed with the perpendicular
INJURIES OF THE SPINE. 501
ligament; and descending to the sacrum, it sends out lateral
processes to the superior and inferior edges of the bodies of the
vertebrae. Intervertebral ligaments also pass in a crucial direction interverte-
from vertebra to vertebra. The articular processes are united by
capsular ligaments, and the transverse processes have ligaments Capsular.
passing from the one to the other. Between the arches of the
roots of the spinous processes is placed an elastic ligament, called
the ligamentum subjlavum, which allows of considerable separa- Ligamentum
subflavum.
tion of the spinous processes ; and, by its elasticity, approximates
them, rendering muscular support for the erect position of the
body less necessary. The vertebrae of the neck are united at
their spinous processes by an elastic ligamentous substance, which
is termed the ligamentum nuchce. Ligaraentum
nuchsB.
The head is connected to the spinal column by capsular liga-
ments, enclosing the condyles of the os occipitis and the articular capsular.
processes of the atlas, or the first vertebra.
j1 circular ligament proceeds from the foramen magnum to the ckcuiar.
edge of the aperture of the first vertebra.
j1 perpendicular ligament passes from the anterior part of the Perpendicu-
foramen magnum to the dentiform process of the second vertebra.
Lateral ligaments proceed from the edge of the foramen Lateral.
magnum and first vertebra on each side, and are united to the
dentiform process of the second vertebra : these ligaments limit
the lateral motions of the head.
The first vertebra of the neck is united to the second by means
of a transverse ligament, which is also fixed to the first vertebra Transverse.
on each side, and passes behind the dentiform process of the
second vertebra.
502 INJURIES OF THE SPINE.
The spinal column, from the two important purposes which it
serves, namely, that of supporting the head and all that part of
the body situated above the pelvis, and also from its containing
and protecting the spinal marrow, upon which the volition and
sensation of the extremities depend, is, by the number of its bones,
the strength of its joints, and its connection with the bones of the
chest, most carefully protected from external injury.
Effects of The effects which are produced by violence done to the spinal
chord, are very similar to those which are produced by injuries
to the brain ; for example :
Concussion,
Extravasation.
Fracture.
Fracture with depression.
Suppuration and ulceration.
mjunes.
Concussion.
CONCUSSION OF THE SPINAL MARROW.
When a person receives a very severe blow upon the spine, or,
from any great force, has it very suddenly bent, a paralysis of
the parts beneath will frequently succeed, in a degree proportion-
able to the violence of the injury; but, after such an effect, the
person, in general, gradually recovers the motion and sensation of
the parts.
CASE.
Case. A man was admitted into Guy's Hospital under the care of
INJURIES OF THE SPINE. 503
Dr. Curry, who had received a severe blow from a piece of wood,
which, falling upon his loins, knocked him down ; and as he came
to the hospital on the regular day of admission, and not imme-
diately after he had received the injury, he was placed amongst
the physicians' patients. His lower extremities were in a great
degree deprived of motion, and their sensibility was much dimi-
nished. When resting upon his back in bed he could ^ slightly
draw up his legs, but could not bend them to a right angle with
the thigh ; and a considerable time elapsed before he could make
the muscles of the lower extremities obey the effort of his will. As
there was still the appearance of severe contusion, and much deep
seated tenderness in the situation of the blow upon the loins. Dr.
Curry ordered blood to be repeatedly drawn away by cupping, and
the bowels to be acted upon by calomel ; and when the pain and
tenderness, in consequence of the contusion, had been removed, a
blister was applied to the loins, and a discharge supported for
three weeks by the application of the unguentum sabinee. The
liniment ammonise was ordered to be daily rubbed upon the lower
extremities. In six weeks the motion and sensation of his legs
had almost entirely returned, and he was then directed to be
submitted to the influence of electricity. By this treatment, in
ten weeks, he completely recovered.
I lately attended a gentleman, who, by a fall from his gig, had
received a severe blow upon his loins, and who had, at first, great
difficulty in discharging both his urine and faeces, but he was
relieved by fomentation and cupping.
504 INJURIES OF THE SPINE.
EXTRAVASATION IN THE SPINAL CANAL.
row exa-
mined in
dissection.
Extravasa- A vGuy scvei'e blow upoii the vertebrae will sometimes produce
extravasation upon the spinal chord, but more frequently upon the
sheath in which it is contained. Of late years it has been our
custom, -in examining dead bodies, to saw off the spinous processes
of the vertebrae, the more accurately to examine the spinal
Spinal mar- maiTow ; aud under such circumstances, in cases of severe injury,
blood has been several times found on the outer side of the spinal
sheath ; and, in one instance, it occurred upon the spinal marrow,
just above the cauda equina.
The case which best illustrates this subject is one which I
visited with Dr. Baillie, and Mr. Heaviside, the particulars of
which I have obtained from Mr. Heaviside, whom I have ever
found ready to make his beautiful anatomical collection useful to
the profession.
CASE.
Case. Master , a fine youth, aged twelve years, in June, 1814,
was swinging in a heavy wooden swing, and in just commencing
the motion forward, was caught by a line which had got under
his chin, by Avhich accident his head Avas violently strained, and
the whole of the cervical vertebrae ; as, however, the line slipt
immediately off, he thought no more of it. Subsequently to the
accident, for some months, he was not aware of any pain or
inconvenience, but his school-fellows observed that he was less
active than usual : instead of filling up his time by play, he would
INJURIES OF THE SPINE. 505
be lying on the school forms, or leaning' on a stile or gate, when
in the fields. They were always teasing him on this account ;
and at last he was persuaded that he was weaker than he used to
be. From this time he continued to decline both in strength and
power. About the middle of May following he came to London.
His complaints were occasional pains in the head, which were
more severe and frequent about the back of his neck (where a
blister had been applied without relief) and down his back. The
muscles at the back of the head and neck were stiff, indurated,
and very tender to external pressure. He felt pain in moving his
head or neck in any direction ; added to these symptoms, there
was a great deficiency in the voluntary powers of motion,
especially in the limbs.
May 18th. Two setons were made in the neck, and he was
ordered various medicines, none of which proved useful.
May 29th. His complaints and the paralytic affection of his
limbs were getting much worse, added to which he felt a most
vehement hot burning pain in the small of his back. This, by
the next day, was succeeded by a sense of extreme coldness in the
same part. Some time after the same pain occurred higher up in
the back, and then disappeared. Pulse and heat natural.
June 3rd. A consultation of Dr. Baillie, Dr. Pemberton, Mr.
A. Cooper, and Mr. Heaviside, was held, and the application of
mercury was determined on. The pil hydr : was taken for a few
days, but as it ran off by the bowels, mercurial frictions were
consequently preferred. He felt his limbs getting every day
weaker, but his neck was more free from pain when moved, and
he was more capable of moving it by his own natural efforts.
T T T
506 INJURIES OF THE SPINE.
June 7th. His respiration became laborious ; he passed a bad
night; on the following* day all his symptoms increased, and at
five in the afternoon he expired.
Examination.
Dissection. The whole contents of the head were carefully examined and
found perfectly healthy; but upon sawing out the posterior parts
of the cervical vertebrae, the theca vertebralis was found over-
flowed with blood, which was effused between the theca and the
enclosing canals of bone. The dissection being further prose-
cuted, this effusion extended from the first vertebra of the neck to
the second vertebra of the back, both included.
The preparation only shews a small proportion of the effused
blood which had become coagulated on the theca, as much of it,
being fluid, escaped in the act of removal.
J. H.
FRACTURE OF THE SPINE.
Produce These accidents, even when the bones retain their situation,
symptoms of ,,.. , . . . , . . /»i
produce, by admitting unnatural variations in the positions ot the
irritation on
pressure
Case.
spinal column, very extraordinary symptoms, and sometimes sud-
den death. Mr. Else, who preceded Mr. Cline as teacher in
anatomy at St. Thomas's Hospital, used to mention the following
case in his lectures.
CASE.
A woman who was in the venereal ward at St. Thomas's
INJURIES OF THE SPINE. 507
Hospital, and who was then under a mercurial course, while
sitting in bed, eating her dinner, was observed to fall suddenly
forward ; and the patients, hastening' to her, found that she was
dead. Upon examination of her body, the dentiform process of
the second vertebra had been broken off, the head, in falling
forwards, had forced the root of the process back upon the spinal
marrow, which had occasioned her instant dissolution.
At the time when I lived with Mr. Cline, as his apprentice, the
following case occurred in his practice, the particulars of which
I cite from his account.
CASE.
A boy, about three years of age, from a severe fall, injured Fracture of
.■,.-, the atlas.
his neck ; and the following symptoms succeeding the accident,
Mr. Cline was consulted.
He was obliged to walk carefully upright, as persons do when symptoms.
carrying a weight on the head ; and when he wished to examine
any object beneath him, he supported his chin upon his hands and
gradually lowered his head, to enable him to direct his eyes
downwards ; but if the object was above him, he placed both his
hands upon the back of his head, and very gradually raised it
until his eyes caught the point he wished to see.
If, in playing with other children, they ran against him, it
produced a shock which caused great pain, and he was obliged
to support his chin with his hand, and to go immediately to
a table, upon which he placed his elbows, and thus supporting
his head he remained a considerable time, until the effects of
T T T 2
process.
508 INJURIES OF THE SPINE.
concussion had ceased. He died about twelve months after
the accident ; and upon the inspection of his body, which was
conducted by Mr. CHne, the first vertebra of the neck was found
broken across, so that the dentiform process of the second ver-
tebra had so far lost its support, that, under different inclinations
of the head, it required great care to prevent the spinal marrow
from being' co sipressed by it ; and as the patient could not depend
upon the action of the muscles of the neck, he therefore used his
hands to support the head during different motions and positions.
Spinous Portions of the spinous processes are sometimes broken off, but
these accidents do not usually affect the spinal marrow, unless
when attended with considerable concussion. j^ir. Aston Key,
in dissecting a subject at St. Thomas's Hospital, found a spinous
process loose, which he kindly brought to me, with the following
account : " The fractured vertebra was the third dorsal : the
cause of the accident I could not ascertain, as it occurred in a
subject brought into the dissecting room. There was a complete
articulation formed between the broken surfaces, which had
become covered with a thin layer of cartilage. The synovial
membrane and capsular ligaments resembled those of other joints,
excepting that the former was more vascular. The fluid within
the joint had the lubricating feel characterizing synovia.
CASE.
A boy was admitted into Guy's Hospital, who had been endea-
vouring to support a heavy wheel by putting his head between
the spokes, and receiving its weight upon his shoulders. The
Case.
INJURIES OF THE SPINE. 509
wheel overbalanced him, and he fell, bent double. When he was
broiig-ht into Guy's Hospital, although he had been perfectly
straight before, he had the appearance of one who had long-
suffered from distorted spine, yet this injury had not produced
paralysis of the lower extremities. Three or four of the spinous
processes had been broken off, and the muscles torn on one side,
so as to give an obliquity to the situations of the fractured
portions. This boy quickly recovered without any particular
attention, and was discharged with the free use of his body and
limbs, but he still remained deformed.
FRACTURES OF THE BODIES OF THE VERTEBRiE,
WITH DISPLACEMENT.
These fractures frequently come under our observation, pro-
ducing: displacement of the vertebrae. As the symptoms and Dispiace-
, . . . . mentofthe
result of the accident differ according to the situation of the ^ertebr«.
fractured bones, these injuries may be divided into two classes :
first, those which occur above the third cervical vertebra ; and,
secondly, those which occur below that bone.
In the first class, the accident is almost always immediately These
accidents
fatal, if the displacement be to the usual extent. Death, in the '^*'^'-
second class, occurs at various periods after the injury. The
origin of the phrenic nerve, from the third and fourth cervical
pair, is the reason of this difference ; for as the parts below are
510 INJURIES OF THE SPINE.
paralyzed by the pressure upon the spinal chord, if the accident
be below the fourth cervical vertebra, the phrenic nerve retains
its functions, and the diaphragm supports respiration ; but if, on
the contrary, the fracture be situated above the origin of this
nerve, death immediately ensues. It is true, that a small filament
of the second cervical nerve contributes to the formation of the
phrenic, but is in itself insufficient to support respiration under
fracture of the third vertebra.
mentbdow The cfFccts whicli arise from fracture and displacement of the
nerve. spiuc, bclow the origin of the phrenic nerve, depend upon the
proximity of the accident to the head. If the lumbar vertebrae
be displaced, the lower extremities are rendered so completely
insensible, that no injury inflicted upon them can be perceived by
the patient. Pinching, burning with caustic, or the application of
ve"rt^bvL. a blister, are alike uofelt. The power of volition is completely
destroyed, not the smallest influence over the muscles remaining.
The sphincter ani loses its power of resistance to the peristaltic
motion of the intestines, and the faeces pass off involuntarily.
The bladder is no longer able to contract, and the urine is retained
until drawn off by a catheter, and yet the involuntary powers of
the limbs remain nearly the same as before. The circulation
proceeds, although perhaps somewhat more languidly, but suffici-
ently to preserve their heat ; and local inflammation can be
excited in them. A blister applied upon the inner side of the
thigh or leg, of which the patient is wholly unconscious, will still
inflame, vesicate, and heal; shewing that the involuntary functions
may proceed in parts which are cut off from their connection with
INJURIES OF THE SPINE. 511
the brain and spinal marrow.* The penis, under these circum-
stances, is generally erect. Patients die from this injury at various
periods, according to the degree of displacement of the vertebrae.
In general, in fractures of the lumbar vertebrae, the patient dies
within the space of a month or six weeks after the injury ; and
usually for some time before death, the urine passes off involun-
tarily, from extreme debility. I remember a patient of Mr. Birch,
in St. Thomas's Hospital, who lived more than two years after
this accident, and then died of gangrene of the nates.
In fractures and displacement of the dorsal vertebrae, the Displace-
ment of the
symptoms are very similar to those described in fractures of the ^°'^^}
•' i •' vertebrae.
lumbar ; but the paralysis extends higher, and the abdomen be-
comes excessively inflated. I remember one of our pupils saying,
when a patient was brought into Guy's Hospital who had suffered
from injury to the dorsal vertebrae, " Surely this man has ruptured
his intestines, for observe how his abdomen is distended." But
the first faecal evacuation relieved this state, and proved that it
had merely arisen from excessive flatulency. This symptom
proceeds from diminished nervous influence in the intestines ; i for
although their peristaltic motion can proceed independently of the
brain and spinal marrow, yet it is quite certain that the involuntary
functions of the intestines, like those of the heart, can be influenced
by the brain and spinal marrow ; for we see even states of the
mind producing affections of the intestines ; one state rendering
* I have always thought that although sensation and volition depend upon the brain, the spinal
marrow, and the nerves, yet the involuntary functions depend principally upon the nerves.
+ Preceding dissolution, in almost all diseases, a great evolution of air into the intestines is
observed, and from the same cause.
512 INJURIES OF THE SPINE.
them torpid, and another irritable; as we see the heart leaping
with joy, and depressed by disappointment. We also observe
pressure on the brain rendering- the intestines very difficult of
excitement, even through the influence of the strongest aperients.
From displacement of the dorsal vertebrae, death sooner succeeds
than in similar injuries to the lumbar, the patient usually sur-
viving the accident not more than a fortnight or three weeks: but
still I knew a case of a gentleman in the City, who met with this
accident, and who lived rather more than nine months. The
period of existence is short or protracted, as the injury is near or
distant from the cervical vertebrce, and as the displacement is
slight or considerable ; it depends also upon the degree of injury
which the spinal marrow has sustained.
Fractures of Fracturcs of the cervical vertebrae, below the origin of the
the cervical ^
vertebrae, p^renic ucrvc, produce paralysis of the arms, as well as of the
lower parts of the body; but this paralysis is seldom complete.
If it occurs at the sixth or seventh vertebra, the patient has some
feeling and powers of motion ; but if at the fifth, little or none.
Sometimes one arm is much more affected than the other, when
the fracture is oblique, and the axillary plexus of nerves is, in
consequence, partially influenced. Respiration in these cases is
difficult, and is performed wholly by the diaphragm, the power
of the intercostal muscles being destroyed by the accident.
The abdomen is also tumid from flatulency, as when the dorsal
vertebrae have sustained injury. The other symptoms, in regard
to the lower extremities, the bladder, and the sphincter ani, are
the same as in fractures of the vertebrae below the cervical.
Death ensues in these cases in from three to seven days, as the
INJURIES OF THE SPINE. 513
disease happens to be seated in the fifth, sixth, or seventh
vertebra. I have scarcely known the subject of this injury to live
beyond a week, and but rarely to die on the second day, although
they sometimes die so early, if the fifth cervical vertebra has
sustained the injury. I have already stated, that in fractures
and displacements above the fourth cervical vertebra, death almost
instantaneously follows. The longest life I have known after
such an accident has been ten minutes.
In the dissection of these cases the following- appearances are Dissection.
found : The spinous process of the displaced vertebra is depressed;
the articular processes are fractured ; the body of the vertebra is
broken through ; for it but rarely happens that the separation and
displacement occur at the intervertebral substance. The body of
the vertebra is usually advanced from half an inch to an inch.
Between the vertebrae and the sheath of the spinal marrow, blood
is extravasated ; and frequently there is extravasation of blood on
the spinal chord itself. The spinal marrow is compressed and
bruised in slight displacements, and is torn through when the
injury has been very extensive; but the dura mater remains
whole. A bulb is formed at each end of the lacerated spinal
marrow, which laceration is usually produced by the bony arch
of the spinous process.
A most interesting case of this accident has been published
by Mr. Harrold, an intelligent surgeon at Cheshunt ; and a
preparation made from his case is preserved in the Museum at
the Royal College of Surgeons.
The outline of the case is as follows :
u u u
514 INJURIES OF THE SPINE.
CASE.
Case. A man, twenty-eight years of age, was knocked down by a
quantity of chalk, which, falling upon him, broke his spine at
the lower part of the dorsal, or the beginning of the lumbar,
vertebra.
The principle upon which Mr. Harrold proceeded was, to pro-
duce union of the bones, by preserving the spine perfectly at rest ;
and to effect this object the patient was placed in a fracture bed,
which permitted him to evacuate his bowels without disturbance.
The urine was drawn off daily by the catheter for several weeks ;
after which time he was able to retain from a pint to a pint and a
half, and to discharge it when he pleased. A wound was pro-
duced upon the sacrum, from the constant pressure of his body
upon the bed ; and, although he was insensible of it, the sore
gradually healed.
Symptoms. At the cud of SIX Hionths his state was as follows : His back
was straight, flexible, and apparently as strong as ever. He
retained and passed his urine, but probably he discharged it more
by the action of the abdominal muscles than by any contraction of
the bladder. He had a stool once in three or four days. His
health and spirits were good, but he had neither sensation nor
volition in the lower extremities. He dressed himself entirely :
he let himself down stairs step by step. He died after the lapse
of twelve months, wanting nine days, from the accident, owing
to a sore on the tuberosity of the ischium, and to disease of
the bone.
Examina- I carcfully examined the preparation, which is preserved in the
Museum of the College, and found the following circumstances :
INJURIES OF THE SPINE. 515
The bodies of the first and second lumbar vertebrge had been
fractured: the first had advanced, and the second had been forced
backwards.
The fracture had united by ossific matter, which had been
spread over the fore part of both vertebrae to a considerable
extent, and a little had been deposited upon the dorsal vertebrae.
The spinal canal had been much diminished by a portion of
bone forced into it from the first vertebra of the loins : this
portion of bone had split the theca vertebralis into two, and
divided the spinal marrow almost entirely : a bulbous projection
of the spinal marrow appeared above and below the bonCj
formed by its divided extremities, which were separated nearly
an inch from each other.
Mr. Brookes also has a preparation in his excellent anatomical
collection, of fracture of the spine at the seventh and eighth
dorsal vertebrae. The person had lived sufficiently long for a ossific
great deposit of ossiffic matter to have formed upon the anterior
and lateral part of the fractured vertebrae. The spinal marrow
was almost entirely torn through, but the spinal sheath remained.
Mr. Brookes could not learn how long the person had survived
the accident.
As to the treatment of these cases, I fear, that whatever be
done, the majority of them will prove fatal.
To bring the spine into its natural form by extension would be
impossible, if it were attempted ; and even if that object were
attained, it would scarcely be practicable to preserve it in its
situation, as the least motion would again displace it. Rest will
U U U 2
516 INJURIES OF THE SPINE.
be essential to ossilic union, but ossific union will not save the
patient if the pressure upon the spinal marrow be not removed.
Operation Mr. Heury Cline \yas the only person who took a scientific view
ciine.' of this accident. He considered it to be similar to fracture wdth
depression of the cranium, and to require that the pressure should
be removed ; and as the cases had proved so uniformly fatal, he
thought himself justified in stepping* out of the usual course, with
the hope of preserving life. He made an incision upon the
depressed bone as the patient was lying upon his breast, raised the
muscles covering the spinal arch, applied a small trephine to the
arch, and cut it through on each side, so as to remove the spinous
process, and the arch of bone which pressed upon the spinal mar-
row. The only case in which he tried it did not succeed ; and,
unfortunately, he did not live to bring his opinion suflftciently
to the test of experiment, to warrant a decided judgment. He
was blamed for making this trial. I am not sure that he would
have been ultimately successful ; but, in a case otherwise without
hope, I am certain that such an attempt was laudable.*
In those cases in which the fii'st and second cervical vertebrae
have been broken and displaced, death, from obstructed res-
piration, is too sudden to allow time for any surgical relief.
* I beg the reader to observe, that this operation is not mine, — that I have expressed some doubts
of its ultimate success ; but I wish the trial to be made, as the only means of deciding positively on its
utility ; and if it saves only a life in one hundred, it is more than I have yet seen accomplished by
surgery.
INJURIES OF THE SPINE. 517
INFLAMMATION AND ULCERATION OF THE
SPINAL MARROW.
The only case which I could determine to be of this nature by
dissection was the following' :
CASE.
A gentleman, who resided about eight miles from London, had, case.
by a fall, received a severe blow upon his spine ; but as it pro-
duced no immediate ill effect he thought very lightly of it. In
going down to his country house he was exposed to the inclemen-
cies of the weather, and he was on a sudden seized with pain in
his back, and paralysis of the lower extremities, retention of urine,
and an involuntary discharge of feeces. I was requested to see
him on account of the retention of urine, and went daily for a
length of time to Wimbledon Common, where he resided, to make
use of the catheter. For several weeks his symptoms remained
unchanged, excepting that now and then the integuments of the
sacrum gave way, and required great attention to prevent a dan-
gerous sore. Towards the close of his existence he complained
of a sense of uneasiness and distention at the upper part of his
abdomen. His appetite failed him ; he rejected his food, and had
a great deal of fever, with quick pulse and profuse perspiration.
He sunk gradually, worn out by irritation.
I removed the spinal marrow, and have it preserved in the
collection at St. Thomas's Hospital.
Upon opening the spinal sheath, a milky fluid was found within Dissection.
518 INJURIES OF THE SPINE.
it, just above the cauda equina ; and higher than this, for the
space of three inches, the spinal marrow was ulcerated to a con-
siderable depth, and was in the softened state which the brain
assumes when it is rendered semifluid by putrefaction. All the
other parts of the body were healthy, excepting the bladder,
which was considerably inflamed and exceedingly extended by
the long continued retention of the urine.
In a case similar to this, it will be necessary to make use of
precautions to prevent inflammation, by cupping or by leeches.
Blisters should be applied ; and if the fever still continue, a
seton should be made, or issues be opened, to prevent the
continuance of inflammation, by producing and supporting ex-
ternal irritation.
EXPLANATION OF PLATES.
FIG. J.
FIG. 2.
iPlL,l.
FIG. 3.
FIG. 5.
PLATE I.
Shews the positions of the limb in the different dislocations
of the thigh-bone, and in the fracture of the cervix femoris.
Fig. 1.
The thigh-bone dislocated upwards, upon the dorsum iiii.
The leg shorter ; the hip projecting ; the knee turned in-
wards, and the patella at least two inches higher than the
other. The foot turned inwards, and the toes resting upon the
metatarsal bones of the other foot. The head of the bone is
thrown back, and the trochanter major forwards.
Fig. 2.
The dislocation downwards in the foramen ovale.
The leg is longer than the other ; the knee is advanced and
separated from that on the sound side ; the toe is pointed
down ; the heel does not touch the ground : the body is bent
forwards.
This is the only accident of this joint in which the leg is
longer.
Fig. 3.
Dislocation in the ischiatic notch.
The leg is shorter ; the patella from half an inch to an inch
above the other ; the foot slightly turned inwards ; the great
toe rests against the ball of the great toe of the other foot ;
the leg is with difficulty separated from the other.
In thin persons the head of the os femoris may be felt a
little above and behind the acetabulum ; more especially if the
surgeon rolls the knee inwards.
Fig. 4.
Dislocation of the os femoris upon the pubes.
Prominence at Poupart's ligament, from the head of the
bone ; the knee turned out, and widely separated from the
other ; leg a little shorter, the one patella being about an
inch higher than the other ; the toe touches the ground, but
the heel does not reach it ; the knee and foot turned out.
Fig. 5.
Fracture of the neck of the thigh-bone.
The leg shorter ; the knee turned out ; the patella from
one to two inches above the other, and sometimes more ; the
foot is generally everted, and does not reach the ground when
the other leg is straight ; the leg is easily drawn to the same
length with the other, and then, if rotated, a crepitus is felt.
ixaiii.
Drawn Sc£naravedhyJ.C.Cajdo7t.
PLATE II.
Shews a dislocation into the foramen ovale which had never
been reduced, and beautifully exhibits the resources of nature,
in forming a new socket for the head of the bone, and allow-
ing of the restoration of a considerable degree of motion.
A. Right and left ilium
B. Ischium
C. Pubes
D. Foramen ovale
E. The left acetabulum
F. Sac0um
G. Os femoris
H. The new acetabulum, formed in the foramen ovale, in
which the head of the thigh-bone was contained, and in
which it was so completely enclosed, that it became im-
possible to remove it, unless a portion of the new socket
were broken away. It was lined by a ligamentous sub-
stance, on which the head of the bone moved to a consi-
derable extent
I. The original acetabulum, situated above the level, and to
the outer side, of the new cavity.
Museum, St. Thomas's Hospital.
n.i
Ul-mm kEiup-tncuJ Inj C.T.CatiUni-
l^,].ll.■.l..■.\ l.v .\«il.-.v I-....1..T. .lij
PLATE in.
Exhibits another view of the same preparation, shewing the
relative situation and appearance of the new and original
acetabulum.
A A. Ilia
B. The original acetabulum, little more than half its natural
size, the edge of the new acetabulum occupying its lower
and anterior part
B. The new acetabulum formed in the foramen ovale, a deep
ossific edge surrounding it; its internal surface is ex-
tremely smooth. The ligament of the foramen ovale has
disappeared, and ossific matter has been deposited in its
stead
D. The thigh-bone removed, and the portion of the new
acetabulum is shewn, which was obliged to be broken off
to separate the thigh-bone from its new socket
E. Head and neck of the thigh-bone; the former a little
changed by absorption, and the latter by ossific deposit.
ix.irr.
1/imm .^TmmiveJ bv i .J.i.
r.il,lisli,.,l bv A.Ui-v Cop.-
PLATE IV.
Shews a dislocation in the ischiatic notch. This is a side
view of the exterior surface of the os innominatum.
A. Ilium
B. Ischium
C. Pubes
D. Trochanter major, covering and concealing the acetabulum
F. Head of the os femoris thrown into the ischiatic notch, and
situated between the posterior and inferior spinous process
of the ilium, and the spinous process of the ischium
G. A new capsular ligament, formed around the head of the
bone, and composed of cellular membrane, condensed by
inflammation.
H. Ligamentum teres, which had been torn through in the
dislocation, as well as the original capsular ligament.
MuseuMf St, Thomas's Hospital.
FI.X
llr.nm i- Ert,'r.iv,,tiyCJMmt,'i
PLATE V.
Exhibits a view of the dislocation of the os femoris upon
the pubes, or forwards and upwards. This preparation beau-
tifully shews the power of nature in accommodating itself to
new circumstances.
AA. Ilia
B. Pubes
C. Ischia
D. Os femoris
E. Trochanter major, occupying the original acetabulum
F. Head and neck of the os femoris, upon the junction of the
pubes and ilium
G. The new cup formed for the neck of the os femoris
H. The femoral artery and vein, passed upon the smooth
surface of the pubes, on the inner side of the new ace-
tabulum.
Museum,) St. Thomas s Hospital.
Tl-JVl,
L-.1 Iw-Arrtli-v C.M.pM-. iKr:
PLATE VI.
Shews the same pelvis, with the thigh-bone removed from
it, to expose the new acetabulum formed by ossific inflamma-
tion on the junction of the pubes and ilium.
A A. Ilia
BB. Pubes
CC. Ischia
D. Acetabulum which was occupied by the trochanter major
EF. The new acetabulum.
Under the line E. the femoral artery and vein took their
course.
r:Lyii][.
Drawn kEnartx^edhyJ.C.Cantan.
.l\il.U^l»<-iLl^- Astl.-^'f.'OlH
PLATE VII.
Dislocation and fracture of the pelvis.
A. Fracture of the pubes on the left side
B. Fracture of the ischium on the same side
C. Dislocation of the right ilium
D. Laceration of the ilio sacral ligament, and separation of
the ilium from the sacrum.
FI,>y!M.
PLATE VIII.
Fig. 1.
Shews the mode of reducing the dislocation upwards, on
the dorsum ilii.
A. The band passed between the thighs to fix the pelvis
B. The pulley fixed above the knee, and the direction shewn
in which the thigh is to be drawn ; viz., obliquely across
the sound thigh, two thirds of its length downwards
C. Head of the bone upon the dorsum ilii
D. Acetabulum.
Fig. 2.
Dislocation in the foramen ovale.
A. Bandage to fix the pelvis
B. The pulley to draw the head of the os femoris outwards
and upwards
C. The surgeon's hand grasping the ancle to draw the one
leg across the other, and to throw the head of the bone
outwards
D. Head of the bone in the foramen ovale
E. Acetabulum, into which the head of the bone is to be
brought.
ri..is:.
l'iil.li>lu-ai.\-i.-twrot.i.c
PLATE IX„
Fig. 3.
This is a view of the mode of reducing the dislocation into
the ischiatic notch,
A. The bandage which fixes the pelvis, and which passes
between the thig-hs
B. The pullies fixed above the knee, and extending in a direc-
tion across the middle of the sound thigh
C. A band surrounding the thigh, by which the surgeon is to
elevate the bone when the extension has been for some
time continued
D. The acetabulum
E. The head of the bone in the ischiatic notch.
Fig. 4.
This figure shews the best mode of reducing the dislocation
of the OS femoris upon the pubes,
A. The bandage to fix the pelvis passing upwards and forwards
B= The pullies which draw the bone downwards and backwards
C. A band passed around the thigh, to enable the surgeon to
raise the head of the bone during the extension
D. Head of the os femoris on the pubes
E« The acetabulum : above and before which the head of the
bone rests upon the junction of the pubes and ilium.
TL.-K.
Fia.5
l-,dJi*lir Afer ArfJrv <
PLATE X.
Shews fractures of the neck of the thigh-bone in man, and
in other animals, as they usually appear on dissection.
Fig. 1.
Ligamentous union shewn.
A. Ilium
B. Pubes
C. Ischium
D. Foramen ovale
E. Os femoris
F. Trochanter major
G. Trochanter minor
H. Neck of the thigh-bone broken within the capsular liga-
ment, and in a great degree absorbed, as it generally is
soon after the accident: its surface smooth from friction,
and rounded to roll upon the hollow of the head of the
bone
I. Head of the bone, hanging in the acetabulum by the
ligamentum teres only, smoothed by one bone rubbing
against the other: a portion of its surface having liga-
ment secreted upon it
K. The capsular ligament exceedingly thickened ; more espe-
cially on that part of the joint which is opposite to the
foramen ovale.
Fig. 2. ^
A. Ilium
B. Pubes
C. Ischium
D. Foramen ovale
E. Os femoris
F. Broken cervix femoris, in a great degree absorbed
G. The head of the bone, supported by the ligamentum teres,
and having no other connection with the body : its sur-
face smoothed by friction when the person begins to
walk.
In each of these preparations the head and neck of the bone,
conjointly, would not form more than one third the natural
length of those parts*
Fig. 3.
The neck of the bone broken in a dog, and no union is
produced but by ligament.
Fig. 4.
The neck of the thigh-bone broken and ununited but by
ligament. The ligament in this experiment was not injured
in breaking the bone.
r.ii,i;.,i,<.avAsii,.v'r„ope
PLATE XI.
Pig. 1.
Shews a preparation of Mr. Langstaff's. A fracture of the
thigh-bone united, as it usually is, by ligament.
A. Head of the thigh-bone
B. Trochanter major
C. Trochanter minor
D. Shaft of the os femoris
E. Capsular ligament excessively thickened
F. Ligamentous productions uniting the neck to the head of
the bone
G. A fork formed in the trochanter minor, which received the
head of the bone, and prevented its further descent.
Fig, 2.
Shews a preparation of Mr. Langstaff's. The upper part of
the thigh-bone broken within the capsule and external to it.
That external to the capsule firmly united by bone, and that
within it ununited.
A. Head of the thigh-bone
B. Trochanter major
C. Trochanter minor
D. Shaft of the bone
E. Ligamentum teres, in its usual situation as regards the
head of the bone, and, as will be seen, not at its centre.
F. Fracture of the thigh-bone external to the capsule, firmly
and well united by bone
G. Fractured cervix within the capsule, still remaining un-
united, even by ligament.
ipi.-xm
J^ir/ 2
S: S7i^ra.ve^l>\' C'J^ GsTi/Pii..
PLATE Xn.
Contains views of the altered state of the neck of the
thigh-bone, by which it is rendered incapable of supporting-
the superincumbent weight of the body, gradually becoming
absorbed, and the head of the bone descends to the trochanter
minor.
Fig- 1-
Is a diagram of the upper part of the thigh-bone, to shew
the change in figure it undergoes from a softened and absorbed
state of its cervix.
A. Natural position of the head of the bone
B. Head of the bone fallen to the trochanter minor
C. Shaft of the thigh-bone.
Fig. 2.
Head of the thigh-bone fallen ; neck of the bone absorbed
and shortened, so that the head and trochanter are brought
together.
A. Head of the bone
B. Trochanter major
C. Shaft of the bone
D. Ligament attached to the remains of the cervix.
Fig. 3.
Shews in a section the internal view of fig. 2. The cervix
femoris in a great degree obsorbed ; the head of the bone and
trochanter major in contact.
A. Head of the thigh-bone
B. Trochanter major
C. Shaft of the bone
D. Ligament entering between the head and cervix
E. Cervix femoris in a great degree absorbed. This disease
occurred on both sides in the same subject.
Fig. 4.
Section of the head and neck of the thigh-bone, the neck in
a great degree absorbed.
A. Head of the os femoris
B. Trochanter major
CC. Remains of the cervix and ligament.
Fig. 5.
Head and neck of the thigh-bone sunken down an inch and
a quarter towards the trochanter minor; neck of the bone
absorbed, shortened, and a line formed at the part at which it
yields to the superincumbent weight, which gives it the
appearance of having been fractured ; wholly, in some sections
of it, partially, in others.
A. Head of the thigh-bone
B. Trochanter major
C. Shaft of the bone
DD. Line of absorption of the phosphate of lime: in the recent
state a ligamento cartilaginous substance is found.
I have several sections of this state of the bone ; two in
which the line of absorption extends quite through; two in
which it extends partially through ; and one in which the line
of abs orption has taken quite a different direction.
Fig. 6.
Shews the greatest descent of the head of the thigh-bone
which I have seen. Let this section be brought in comparison
with fig. 1, and the great alteration which it has undergone
will be at once obvious: the head of the bone, instead of
being at A. is at B. of fig. 1, pressed down by the superin-
cumbent weight of the body.
A. Head of the bone
B. Trochanter major
C. Shaft of the bone.
Thus the neck of the thigh-bone undergoes great changes
in form, length, and direction. .
Fig. 7.
Shews the changes which are sometimes found in old and
bed-ridden persons.
A. Head of the thigh-bone
B. Trochanter major
C. Cancelli of the neck of the bone increased in coarseness
by absorption, so as to render the bone weaker, and,
when dried, diaphanous
D. Piece of bone added to the upper part of the cervix
EE. A larger piece of bone added to the lower part of the
cervix, to support the weakened neck of the bone.
If sections are made transversely of the neck of the thigh-
bone in old persons, the neck of the bone is found so exceed-
ingly spongy, as to be unable to bear even slight concussion.
Fig. 8.
Is a fracture of the neck of the thigh-bone in a person
between thirty and forty years of age. The preparation was
lent me by Mr. Herbert Mayo.
The bone was shortened an inch only, because a fork in the
trochanter minor has caught the neck of the bone, and pre-
vented its further descent. The person lived nine months after
the accident ; and, notwithstanding the age being favourable,
the bones being nearly in apposition, ligamentous union only
was produced.
A. Head of the bone
B. Trochanter major
C. Shaft of the bone
D. Fork in the trochanter minor
E. Fracture united by ligament only.
It is curious to observe how little the head of the bone is
changed in this fracture after nine months. Any other bones
in the body but those forming parts of articulations would be
loaded with ossific matter.
FIG. 6
Draxm .i Engraved by C.J. Can ten ^
PubTishea lyAstaeryCoopnMSaa.
PLATE XIII.
Fig. 1.
Fracture of the cervix femoris, sent me by Mr. Powell,
surgeon, of Coram-street, Brunswick-square, in Avhich the
neck of the thigh-bone has been forced into the cancellated
structure.
A. Acetabulum
B. Head of the thigh-bone
C. Trochanter major
D. Trochanter minor
E. Shaft of the thigh-bone
F. Neck of the thigh-bone united to the cancelli, into which it
had been forced
G. Addition to the trochanter major, which occasionally rested
on the ilium
H. Addition to the trochanter minor, which occasionally rested
on the left of the acetabulum ; and thus the bone became
supported by these processes under the weakened state of
the cervix.
Fig. 2.
Anatomical view of the head of the thigh-bone and capsular
ligament.
A. Head of the thigh-bone
B. Thigh-bone
C. Reflected synovial surface, vessels seen under it
D. Depression for the ligamentum teres
EE. Capsular ligament, and synovial secreting surface
F, Place of reflection of the synovial surface
G. Reflected ligament upon the neck of the bone, which sinks
into its pores, and envelopes the neck of the bone as a
periosteum ; conveying vessels, but diff*ering from perios-
teum in the strength, arrangement and appearance of its
fibrous structure.
Fig. 3.
A. Head of the bone
B. Ligamentum teres
C. Thigh-bone
D. Trochanter major
E. Trochanter minor
F. Capsular ligament
GG. Insertion of the capsular ligament into the bone
H. A band of reflected ligament and synovial secreting
surface with its vessels opposite the trochanter minor.
Nearer to the bone the reflection of the ligamentous
periosteum is seen
H. Another band opposite the trochanter major, the blood-
vessels in it
I. The reflected ligament forming a sheath to the bone is seen
upon the cervix femoris.
In reviewing' what I have written on the structure of the
head and neck of the thigh-bone, I fear that some misconcep-
tion might arise of the passage, page 121, in which I say that
the head and neck of the bone are supplied with vessels from
the reflected ligament and ligamentum teres. Now I do
not mean that this is the only supply, for it is well known that
vessels pass through the interior of the neck of the bone ; but
as these are torn through by the fracture, only those of the
untorn reflected ligament and ligamentum teres remain, and
it is principally those of which I have given a view in the
plate, No. 13. In the fetal bone, in this plate, the interior
vessels are slightly tinted.
Fig. 4.
Fsetal thigh-bone.
A. Head of the bone
B. Trochanter major
C. Shaft of the bone
D. Ligamentum teres, with its vessels
E. Ossific vessels of the head of the bone.
Fig. 5.
Extremity of the os calcis, cut off* and drawn up by the
action of the gastrocnemius muscle, in the rabbit.
A. Os calcis
B. Portion of bone detached from it
C. Union by ligament.
Fig. 6.
Longitudinal section of the head of the thigh-bone in a
dog, in part within and in part external to the ligament.
A. Head of the bone
B. Portion of the head of the bone broken off longitudinally,
and reunited by an ossific process. In this experiment,
both the capsular ligament and periosteum afforded
nourishment to the bone.
PLATE XIV.
Shews the seat of fracture of the cervix femoris within the
capsular ligament.
A. Head of the bone
B. Cervix femoris
C. Capsular ligament.
Fig. %
Exhibits the seat of fracture of the trochanter major, often
mistaken for fractured cervix femoris. This fracture unites
by bone.
A. Head of the bone
B. Shaft of the os femoris
C. Fracture through the trochanter.
Fig. 3.
Fracture of the trochanter, sent me by Mr. Oldknow, of
Nottingham.
A. Head of the bone
B. Broken trochanter major
C. Broken trochanter minor
D. Neck of the thigh-bone
E. Shaft of the bone.
Fig. 4.
Shews the bone sent me by Mr. Roux, in which the neck of
the OS femoris is driven into the cancellated structure of the
shaft of the bone, where it unites by means of bone, as in Mr.
Powell's case.
Fig. 5.
The inclined plane for simple fracture of the thigh and
trochanter major.
A. Frame to rest upon the bed
B. Two lateral supporters to A.
C. The plane for the thigh
D. The plane for the leg
E. The joint.
Two boards, nailed together, with the inclination as described
in the plate, answer nearly the same purpose.
Fig. 6.
The thigh-bone fractured below the trochanter minor, and
drawn into a most deformed union by the action of the psoas
and iliacus internus muscles.
Museum, St. Thomas's Hospital.
Fig. 7.
Dislocation of the knee from ulceration of the lig'ament,
with subsequent anchylosis of the tibia forwards, at right angles
with the thigh-bone, and of the patella to the thigh-bone.
A. Shaft of the bone
BC. Tibia projecting forwards, and anchylosed to the os femoris
D. Patella anchylosed
E. Ligamentum patellae.
Amputated by Mr. Cline.
Museum^ St. Thomas's Hospital.
Fig: 8.
Fracture of the human thigh-bone through the trochanter
major, in which ossific union has taken place, the fracture
being external to the ligament.
A. Fracture.
This case shews the tendency to eversion of the knee and
foot in this injury, and the necessity for guarding against it by
attention to the position of the foot during the union.
PLATE XV.
The thigh-bone broken just above its condyles and united.
Laceration of the rectus muscle, and great overlapping of the
bone.
A. Os femoris
B. Tibia
C. Patella
D. Rectus muscle lacerated
EE. Os femoris broken and overlapping, but united
F. Point of the os femoris projecting through the rectus
muscle, preventing complete extension, and exceedingly
limiting the flexion of the joint.
In Mr. Pateys possession.
p]L.:x^i.
PuHisliel ■by-'^'^'iey Cooper 1822.
PLATE XVI.
Fig. 1.
Shews an anterior view of a dislocation of the thigh at
the knee-joint outwards.
A. Muscles of the thigh
B. Patella
C. External condyle of the os femoris, which had pushed
through the ligaments and skin
D. One semilunar cartilage
E. The other semilunar cartilage
F. Head of the tibia
G. Leg
HH. Capsular ligament.
Fig. 2.
Posterior view of the same knee.
A. Muscles of the thigh
B. Gastrocnemius
C. Sciatic nerve
D. Popliteal vein
E. Popliteal artery
F. External condyle, which had torn the capsular ligament and
muscles posteriorly
G. Internal condyle, which had also torn the ligament and
muscles
H. Torn ligaments.
From Mr. Oliver of Brentford.
Fig. 3.
Shews the thigh-bone in a compound fracture at its condyles
into the knee-joint.
Museum, St. Thomas's Hospital.
Fig. 4.
Longitudinal fracture of the patella, in which the separation
of the bone is very slight, yet it is united by ligament only.
A. Tendon of the rectus femoris
B. Ligamentum patellae
C. Patella
D. Ligamentous union.
Drawn by Mr. Sylvester.
Museum, St. Thomas's Hospital.
^<s^.^r^
'**.;
PLATE XVII.
Different views of fracture of the patella.
Fig. 1.
Fracture of the patella, with ligamentous union and great
separation of the bone.
The extent of separation depends upon the degree of lace-
ration of the capsular ligament, and of the tendons of the
vasti muscles which are spread over it.
A. Upper portion of the patella drawn up by the action of
the rectus and vasti
B. Lower portion of the bone
C. to A, Original ligament
C. to B. New ligament, which, from its length, excessively
diminished the power of the extensor muscles.
Fig. 2.
Patella of a dog broken and united by ligament.
Fig. 3.
Patella of a rabbit broken.
A. Coagulated blood between the bones.
Fig. 4.
Patella of a rabbit broken.
A. The blood absorbed, and adhesive matter in its stead.
Fig. 5.
Patella of the rabbit broken and united by ligament ; from
A. toB.
Fig. 6.
Longitudinal fracture of the patella in the dog.
A. One portion
B. The other.
Ligament seen between the two.
Fig. 1.
Patella broken longitudinally, so that there is no separation,
and it is united by bone.
A. Rectus muscle
B. Ligamentum patellae
C. Longitudinal fracture united.
By its side is seen the patella separated and macerated, and
there was slight ossific union.
All injjhe Museum, St. Thomas's Hospital.
PLATE XVIII.
Fig, 1.
Shews the dislocation of the tibia inwards at the ancle-
joint.
A. Malleolus internus of the tibia thrown on the inner side of
the astragalus
B. A portion of the tibia split off
C. Fibula broken
D. Broken portion of the tibia adhering by ligament to the
fibula
E. Malleolus externus of the fibula, with the broken portion
of the tibia adhering to it
F. Astragalus thrown outwards.
Museum, St Thomas's Hospital,
Fig, 2.
Shews the dislocation of the tibia outwards at the ancle -
joint.
A. Tibia
B. Fibula
C. Os calcis
D. Fracture of the tibia at the malleolus internus, which has
become reunited
E. Extremity of the fibula broken
F. Tibia thrown on the outer side of the articulatory surface
of the astragalus, to which it is anchylosed.
Museum, St. Thomas's Hospital.
Fig. S.
Shews a fracture of the tibia and fibula at the ancle-
joint, sent to me by my friend, Mr. Hammick, Surgeon of
the Plymouth Naval Hospital.
A. Tibia fractured
B. Fracture of the fibula
C. Astragalus
E. Shell of the bone surrounding a fragment of bone, and so
completely enclosing it that it could not be removed,
and amputation became necessary.
Fig. 4.
The fragment of bone seen separately.
PLATE XIX.
Partial dislocation of the tibia forwards, at the ancle-joint.
Fig. ].
A. The tibia thrown forward over the os naviculare
B. The astragalus
C. New articulatory surface of the tibia
D. The portion of the astragalus behind the tibia.
Fig. 2.
Opposite view of fig. 1.
A. The tibia thrown forwards
B. New articulatory surface of the tibia
C. Astragalus
D. Fibula broken and reunited
E. Malleolus externus of the fibula
F. Astragalus behind the tibia.
Fig. 3.
Comminuted fracture of the tibia at the ancle-joint, which
rendered amputation necessary.
A. Astragalus
BB. Fibula fractured
CC. Tibia shattered into the joint.
rL.xx<
Tl&l
FIG 2
JJrawfi k-Zjup'ave^il'i/ C.XQmf^TJA
IViblishcd lyAjnliy Cf>cip*r,li
PLATE XX.
Two views of dislocation of the astragalus, in the case
of Mr. Downes, in whom the astragalus sloughed away.
The drawing was made when the bone began to loosen.
-?S^^^S^.
i
I'liMished byAsUcv Co.ipci
PLATE XXI.
Dislocation of the os humeri in the axilla, as it appears in
the first dissection of the parts.
A. Clavicle
B. Scapula
C. Os humeri, with the biceps before, and triceps behind, the
bone
D. Subscapularis
E. Teres major
F. Latissimus dorsi
G. Pectoralis major
H. Nerves of the axillary plexus and axillary artery and vein,
which are seen cut across at the lower part of the plexus;
the cutaneous nerve seen passing through the coraco
brachialis muscle
I. Coracoid process
K. Head of the bone dislocated in the axilla
L. Capsular ligament and tendon of the subscapularis muscle
torn, through which laceration the head of the bone
escaped from the glenoid cavity.
FIG. I
Puhlishcd by AsUcy Cooper. 1S22.
PLATE XXII.
Fig. 1.
Shews the new socket which has been formed on the inner
side of the inferior costa of the scapula, in a dislocation of
the OS humeri into the axilla.
A. The scapula
B. The coracoid process of the scapula
C. The glenoid cavity, with the acromion above it
D. The new socket for the head of the os humeri.
Fig. 2.
Partial dislocation of the os humeri forwards. This drawing
was made from the dissection of Mr. Patey, in Dorset-street.
A. Clavicle
B. Acromion
C. Coracoid process
D. Scapula
EE. Os humeri; head of the bone somewhat altered
F. Glenoid cavity
G, New smooth cavity for the head of the os humeri, which
extended from the edge of the glenoid cavity to the
coracoid process of the scapula.
piLoJsxjnui.
ruWifhcA l)yArtlc;y Too
PLATE XXIII.
Fig. 1.
Dislocation of the os humeri forwards, under the clavicle,
and behind the pectoral muscle.
A. Clavicle
B. Scapula
C. Acromion
D. Glenoid cavity of the scapula, from which the os humeri
had been thrown ; and on the inner side of this cavity is
seen the coracoid process
£. The head of the os humeri, with the tendon of the biceps
passing over it ; the head of the bone under the middle
of the clavicle, in the centre of the scapula, and on the
inner side of the coronoid process
F. Portions of the new ligament, which enclosed the head of
the bone
Removed from a patient in St. Thomas's Hospital by
Mr. Coleby.
Museum, St. Thomas s Hospital.
FjL.XMjIM.
JFial
PubHdicd V .\s^t^ Cooper .1822 .
PLATE XXIV.
Fig. 1.
Shews a dislocation of the os humeri in the axilla.
A. The clavicle
BB. The scapula
C. The OS humeri
D. The biceps flexor cubiti
EE. Subscapularis muscle
F. Laceration of the capsular ligament, and of the tendon of
the subscapularis
G. Head of the bone thrown on the inner side of the inferior
costa of the scapula.
Fig. 2.
Dislocation of the ulna and radius backwards.
A. Os humeri
B. Ulna
C. Radius
D. Biceps flexor cubiti, inserted into the tubercle of the radius
E. Brachialis internus, inserted into the coronoid process of
the ulna
F. Triceps extensor cubiti, inserted into the olecranon
G. Internal condyle of the os humeri
H. Olecranon and coronoid process, thrown behind the articu-
latory surface of the os humeri ; the coronoid process is
received into the posterior cavity of the humerus.
Museum, St. Thomas's Hospital.
PL.SSYo
FIG. I
FIG. 2
RibKshed WAstley Cooper. 1322
PLATE XXV.
Fig. 1.
A dislocation of the ulna backwards.
A. Os humeri
B. Ulna
C. Radius
D. Insertion of the biceps flexor cubiti into the tubercle of the
radius
E. Olecranon thrown behind the os humeri
F. Some appearance of injury to the internal condyle of the
OS humeri.
Museum i St. Thomas's Hospital.
Fig. 2.
Opposite view of the same preparation.
A. Os humeri
B. Ulna
C. Radius
D. Insertion of the biceps into the tubercle of the radius
E. Olecranon thrown backwards
F. Head of the radius, which, by its pressure against the
external condyle of the os humeri, has produced a socket
there for itself.
Fig. 3.
Dislocation of the Radius. The bone is thrown upon the
external condyle, and upon the coronoid process of the ulna.
A. Os humeri
B. Ulna
C. Radius
D. Olecranon
E. Head of the radius. The coronary ligament and a part of
the interosseous ligament is torn through, and the head
of the bone is thrown upon the coronoid process of the
ulna, and external condyle of the os humeri.
Museunif St. Thomas's Hospital.
FVibKshcd "bvibdcT Cooper.i3s:
iLTiflnnai /'V CJ-Cnnten.
PLATE XXVI.
Shews a dislocation of the radius backwards, behind, and
to the outer side of the external condyle of the os hun i.
A. Os humeri
B. Radius
C. Ulna
D. Internal condyle of the os humeri
E. Coronoid process of the ulna ; the capsular lig-ament being-
opened to shew D. and E.
F. The head of the radius dislocated backwards and outwards
G. The coronary ligament torn through.
Given by Mr. Poingdestre. Drawn by Mr. Sylvester.
MuseuMi St. Thomas's Hospital.
PL.XXMl,
FI& 3
I'iitli;b.:d by Astlcy Cooper, 1322.
PLATE XXVII.
Fig. 1.
Shews a fracture of the external condyle of the os humeri,
still disunited.
A. Os humeri
B. Ulna
C. Radius
D. Fractured external condyle within the ligament ; no at-
tempt made to unite it ; the broken portion unaltered
E. Head of the radius
Museum, St. Thomas's Hospital.
Fig. 2.
Fracture of the external condyle of the os humeri, and of
the coronoid process of the ulna.
A. Os humeri
B. Ulna
C. Radius
D. Head of the radius
E. External condyle fractured externally to the capsular liga-
ments ; great attempts made by nature to unite it, and
the form of the bone changed
F. Coronoid process of the ulna broken off, and united by
ligament only to the ulna ; no attempt made to produce
ossific union. This portion of the coronoid process was
seated within the capsular ligament.
Museum, St. Thomas's Hospital.
Fig. 3.
Fractured olecranon.
A. Os humeri
B. Ulna
C. Radius
D. A portion of the triceps extensor cubiti
E. Olecranon broken and drawn up by the triceps
F . Shaft of the ulna where the olecranon is broken from it
G. The new ligament, which has joined the olecranon to the
ulna.
Museum, St. Thomas's Hospital.
FIG. 3.
JPLJXXMIl.
J^IG. 4. '
PuHishcdljrAsil'^- Cooper, 1802.
PLATE XXVIII.
Fig. 1. ■
Shews a fracture of the inferior extremity of the radius, and
dislocation of the ulna forwards.
A. Radius
B. Ulna
C. Lig-amentum annulare carpi
D. Ulna thrown forwards upon the os orbiculare
E. Broken extremity of the radius : the shaft of the bone
thrown forwards, and the lower extremity of the bone
remaining in its natural situation. On the shaft of the
bone, just above the fracture, is seen the attachment of
the pronater quadratus.
Museum, St. Thomas's Hospital.
Fig. 2.
Shews a compound dislocation of the ulna backwards, with
a compound and comminuted fracture of the radius.
A. Radius
B. Ulna
C. Carpus
D. Ulna dislocated backwards, being thrown behind the
extremity of the radius
T
E. Fragments of the broken radius extremely comminuted :
the tendon of the extensor carpi radialis brevior torn
through.
Museum, St. Thomases Hospital.
Fig. 3.
Dislocation of the second phalanx of the finger forwards,
and of the first backwards.
A. First phalanx
B. Second phalanx
C. Third phalanx
D. Dislocated extremity of the first phalanx
E. Dislocated second phalanx
F. New capsular ligament covering the ends of the dislocated
bones.
Fig. 4.
Compound dislocation of the first phalanx of the thumb.
A. Metacarpal bone
B. First phalanx thrown backwards
C. Second phalanx
D. First phalanx dislocated
E. Tendon of the flexor longus pollices torn through.
In the treatment of this accident the end of the bone is to
be sawn away.
Museum, St. Thomas's Hospital.
jFICt.1
rublishccl by Astlcv Cooper. 18'i&.
Dratt-n ^Enorawd hv ( '. J. Canten.
PLATE XXIX.
Fig. 1.
Shews a view of a dislocation of the os humeri into the
axilla on the right side.
Fig, 2.
Is a view of the dislocation of the os humeri forwards,
behind the pectoralis major, and under the clavicle.
Fig. 3.
The bones of the trunk, shewing" the seats of dislocation
of the clavicle and os humeri.
A. Sternal end of the clavicle thrown upon the sternum
B. Scapular end of the clavicle thrown upon the spine of the
scapular
C. Spine of the scapular
D. The glenoid cavity
E. Coracoid process
F. Head of the os humeri thrown into the axilla
G. Head of the os humeri thrown forwards upon the second
rib under the clavicle, and upon the inner side of the
coracoid process in the dislocation forwards.
Fig. 4.
Shews the situation of the head of the os humeri, when
dislocated backwards upon the scapulae.
A. Dorsum scapulae
B. Os humeri
C. Head of the os humeri on the dorsum scapulae.
Fig. 5.
Shews a dislocation of the astragalus outwards.
A. Malleolus externus
B. Astragalus thrown outwards : the foot resting upon its
outer edge.
Fig. 6.
A. Ulna thrown back
B. Radius thrown with the ulna
C. Hollow above the elbow.
aniiin,<f:>vnnY.i /■,■ .
PLATb; XXX.
Fig. 1.
Shews the mode which I ahnost constantly pursue of re-
ducing' recent dislocations of the os humeri, by placing the
heel in the axilla, and by extending the arm either from above
the elbow or from the wrist.
Fig. 2.
Mode of reduction by the pulley ; shewing the manner in
which the scapula is fixed by a bandage which receives the
arm, and the pullies applied above the elbow ; as well as the
direction in which extension is to be made in dislocation in
the axilla. If the dislocation be forwards under the clavicle,
the arm must be somewhat lowered to avoid the coracoid
process.
Fig. 3.
Shews the mode of reducing the dislocation downwards, by
the knee in the axilla.
PLATE XXXr.
Fig. 1.
Shews an altered state of the neck of the thigh-bone from
disease, which might be mistaken for fracture and union. The
same appearance, in a less degree, is sometimes seen in the
upper part of the thigh-bone in very old persons ; the head
and neck of the bone falling down upon its shaft at the
trochanter minor, and the neck of the bone absorbed.
Fig. 2.
Fracture of the cervix scapulae.
A. Spine of the scapula
B. Coracoid process
C. Glenoid cavity broken off by a fracture through the neck
of the scapula.
Fig. 3. Fracture of the acromion.
4. Fracture of the cervix humeri.
5. Fracture of the internal condyle of the os humeri.
— — 6. Fracture of the external condyle of the os humeri.
7. Fracture of the olecranon.
8. Fracture of the coronoid process of the ulna.
Fig, 9. Clavicle bandage, with the pads under the axilla, to
throw the head of the os humeri from the side ; used
in fractured clavicle ; in dislocations of that bone ;
and in fracture of the cervix scapulae.
10. Lateral splints for fractures of the elbow-joint.
11. Back splint for the arm, with the hinge at the
elbow, for fractures of the condyles when requiring
motion.
12. Mode of reduction of the thumb.
13. Loop used for the foregoing purpose, called by
sailors the clove hitch, composed of two circles, with
the ends between them.
14. Bandage for the fracture of the olecranon.
15. Common mode of bandaging for the fractured patella.
16. Leathern strap buckled above the patella, with
another strap passing under the foot, which I em-
ploy for fractured patella.
17. Long splint for fractured thighs. Its upper part
rests against the pubes, and is buckled around the
upper part of the thigh. The splint passing down
on the inner side of the thigh and leg, with a screw
to add to its length, and a boot attached to it to
confine the splint to the foot.
Fig. 18. Splint, with a foot-piece on each side, for dislocations
and fractures at and near to the ancle-joint.
Fig. 19.
Bandage used in the case, related by Mr. Harris, «f
Reading-, of injury to the upper part of the thigh-bone.
A. A pad buckled around the pelvis, to support the trochanter
B. Wedge to support the thigh-bone
C. Foot supporter
D. Portion of the mattress which drew out to slide a bed-pan
under the patient.
TPJLATE :SXX11.
Fj^J.
Itff.3.
Fig 2
Droim &Entput'ed by C ■J'Canton,.
fiiMjskea' fy-^s-aey Cooper, WS4- .
PLATE XXXII.
Fig. 1.
Shews the union of the radius after fracture, and a liga-
mentous union of the ulna. Mr. Cline used to attribute the
want of union, in such cases, to the muscles drawing" the bones
from each other, hence the pronator quadratus would produce
this effect; in the os humeri, the coraco brachialis would, in
a similar manner, prevent union. Whatever prevents pressure
of one bone against the other, will have a tendency to produce
that effect. Want of pressure is one principle of nonunion.
A. Radius
BB. Section of the ulna
C» Interosseous ligament
D. Pronator quadratus muscle
E. United radius
F. Ulna united by ligament.
Fig. 2.
Fracture of the cranium,^ and a portion of bone removed by
the trephine.
A. Os frontis
B. Parietal bone
C. Large aperture in the skull remaining unfilled, except at
its edges, although it had the appearance of being an
accident of ancient date.
D. Fracture ununited.
In examining these cases, I have found that the pericranium
has been much thickened at the aperture. The dura mater
greatly thickened beneath the openings, and a ligamentous
substance unites the dura mater to the pericranium. Some
ossific matter is added to the edge of the opening in the bone,
but unless the opening be small, it is rarely filled by bone.
Fig. 3.
Tibia ununited after fracture ; yet in these cases the person
walks with a much less halt than would be expected by the
surgeon who had not witnessed similar examples.
A A. Tibia
B. Nonunion of the tibia
CCC. Fibula enormously enlarged and curved, so as to bring
the foot near to the axis of the body. The upper part of
the fibula little less than the tibia
D. Interosseous ligament
A lady from Salisbury, whom I lately saw, walked extremely
well across my room, although her tibia was ununited after
fracture.
Pilate 3>s>.
Fif. 7.
Fit^ ^
/^y>lu-ked dyJs/2ev Co(7prj-. f<f^-f .
PLATE XXXm.
Fig. 1.
Shews the radius of a dog, from which half an inch of bone
had been removed. It had not united, but, from the appear-
ance of the callus, probably would have united had the animal
lived longer than two months.
A A. Space produced by the removal of the bone.
Fig. 2.
Portion of the radius removed, an inch in length. Mode of
union shewn.
A A. Each end of the radius united with the ulna only.
Fig. 3.
Two inches of the radius removed. A ligamentous union
of the radius to the ulna was produced, and the ulna was
enlarged opposite to the space produced by the removal of
the radius.
Fig. 4.
Is a curious result of an experiment in which an inch of
bone was removed from the radius, and the ulna was acci-
dentally broken at the time. The radius produced callus,
which did not reach from bone to bone, but the ulna, at its
fractured part, sent in two portions of bone to fill the space
between the ends of the radius.
A A. Space between the ends of the radius
B B. Fracture of the ulna, with two portions of bone pro-
ceeding into the inter-space of the radius.
This experiment explains the cases of apparent union
between remote portions of bone, when a piece of the tibia has
been removed, and the fibula at the same time fractured : this
is fully exemplified in the case published by Mr. Dunn, a very
intelligent surgeon at Scarborough, who has had the kindness
to send me a cast of the leg of his patient.
PiibHsliea 'by Asdey Cooper. 1824 .
PLATE XXXIV.
Fig. 1.
Shews a dislocation of the scapular end of the clavicle upon
the acromion ; the clavicle is seen projecting over the spine
of the scapula.
A A. Clavicle
B. Scapula
C. Spine of the scapula
D. Acromion
E. Scapular end of the clavicle thrown over the acromion
F. The conoid ligament almost entirely converted into bone,
and anchylosing the clavicle to the scapula.
Fig. 2.
Shews a fracture of the acromion united by ligament.
A. Portion of the scapula
B. Spine of the scapula
C. Glenoid
D. Coracoid process
E. Acromion
F. The fracture of the acromion united at its edge by the
ligament
G. Which has been turned aside to shew ligamentous granu-
lations upon the broken surfaces.
_t
Fig. 3.
Is a very curious preparation of dislocation of the os humeri
in the axilla, and fracture of the cervix within the capsular
ligament, forming there a new joint, the fracture not having
united.
A A. Scapula
B. Portion of the clavicle
C. Acromion
D. Coracoid process of the scapula
E. Acromio coracoid ligament
F. Head of the os humeri dislocated
G. Tubercles of the os humeri
H. Os humeri
I. Tendon of the biceps
K. The new joint from the fracture.
Fig, 4.
Fracture of the os humeri below the capsular ligament
united.
A. Head of the os humeri
B. Os humeri
CC. Fracture united.
F. WARR, PRINTER, RED WON PASSAGE, HOLBORN.
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